Provider Demographics
NPI:1417448259
Name:COUSINS, BRANDON WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WAYNE
Last Name:COUSINS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 WILDWOOD PKWY STE 5
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2667
Mailing Address - Country:US
Mailing Address - Phone:636-227-8400
Mailing Address - Fax:
Practice Address - Street 1:485 WILDWOOD PKWY STE 5
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2667
Practice Address - Country:US
Practice Address - Phone:636-227-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180169431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice