Provider Demographics
NPI:1336702521
Name:MCDONALD, BRANDON W
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:W
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W 42ND ST APT 30M
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-2083
Mailing Address - Country:US
Mailing Address - Phone:585-402-5421
Mailing Address - Fax:
Practice Address - Street 1:66 SOMME ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3612
Practice Address - Country:US
Practice Address - Phone:973-578-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062205-011223P0221X
NJ22DI0-27816001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry