Provider Demographics
NPI:1275706301
Name:KANER, BRANDI KAYE
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:KAYE
Last Name:KANER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1278 HARTLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1135
Mailing Address - Country:US
Mailing Address - Phone:815-304-4956
Mailing Address - Fax:
Practice Address - Street 1:21 HERITAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1465
Practice Address - Country:US
Practice Address - Phone:815-936-3232
Practice Address - Fax:815-936-3236
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILK560-0718-2640122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist