Provider Demographics
NPI:1619396652
Name:CLARA W BRANNAN DDS, PS
Entity Type:Organization
Organization Name:CLARA W BRANNAN DDS, PS
Other - Org Name:SOUTH HILL CHILDREN'S DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:WINONA
Authorized Official - Last Name:BRANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-209-7555
Mailing Address - Street 1:11102 SUNRISE BLVD E STE 108
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8846
Mailing Address - Country:US
Mailing Address - Phone:253-209-7555
Mailing Address - Fax:
Practice Address - Street 1:11102 SUNRISE BLVD E STE 108
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8846
Practice Address - Country:US
Practice Address - Phone:253-209-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000109811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty