Provider Demographics
NPI:1326597238
Name:BRANSHAW, NICOLAS ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:ROBERT
Last Name:BRANSHAW
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 1:7117 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-1450
Mailing Address - Country:US
Mailing Address - Phone:715-828-9655
Mailing Address - Fax:
Practice Address - Street 1:7117 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-1450
Practice Address - Country:US
Practice Address - Phone:715-828-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10013981223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist