Provider Demographics
NPI:1467991133
Name:BRANNON, KHALEILA (DDS)
Entity Type:Individual
Prefix:
First Name:KHALEILA
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PARKLAWN DR UNIT 814
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-8137
Mailing Address - Country:US
Mailing Address - Phone:443-123-2345
Mailing Address - Fax:
Practice Address - Street 1:1500 PARKLAWN DR UNIT 814
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-8137
Practice Address - Country:US
Practice Address - Phone:410-123-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15994122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist