Provider Demographics
NPI:1528394129
Name:DESANTIS, BRIANNE COURTNEY (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRIANNE
Middle Name:COURTNEY
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 RIVER LN
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-3555
Mailing Address - Country:US
Mailing Address - Phone:386-441-7719
Mailing Address - Fax:
Practice Address - Street 1:106 N OLD KINGS RD
Practice Address - Street 2:SUITE C
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9505
Practice Address - Country:US
Practice Address - Phone:386-672-4981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics