Provider Demographics
NPI:1518355841
Name:MELISSA BRANDNER PROF. LLC
Entity Type:Organization
Organization Name:MELISSA BRANDNER PROF. LLC
Other - Org Name:PARKSIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRANDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-498-4746
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-0580
Mailing Address - Country:US
Mailing Address - Phone:605-498-4746
Mailing Address - Fax:605-498-9012
Practice Address - Street 1:910 N MAIN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TEA
Practice Address - State:SD
Practice Address - Zip Code:57064-0580
Practice Address - Country:US
Practice Address - Phone:605-498-4746
Practice Address - Fax:605-498-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty