Provider Demographics
NPI:1255496717
Name:WRIGHT, BRANDON RAY (DMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:RAY
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847
Mailing Address - Country:US
Mailing Address - Phone:406-273-0490
Mailing Address - Fax:
Practice Address - Street 1:108 TYLER WAY
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847
Practice Address - Country:US
Practice Address - Phone:406-273-0490
Practice Address - Fax:406-273-7969
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0032552Medicaid
MT0032994OtherCHIPS ST OF MT