Provider Demographics
NPI:1598178295
Name:BRANNON, RANDALL STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:STEPHEN
Last Name:BRANNON
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 1:350 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1049
Mailing Address - Country:US
Mailing Address - Phone:304-927-2775
Mailing Address - Fax:304-927-2777
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1049
Practice Address - Country:US
Practice Address - Phone:304-927-2775
Practice Address - Fax:304-927-2777
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice