Provider Demographics
NPI:1629038708
Name:BRANDEBURA, JOHN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BRANDEBURA
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2407 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3736
Mailing Address - Country:US
Mailing Address - Phone:479-484-1011
Mailing Address - Fax:479-484-1205
Practice Address - Street 1:2407 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3736
Practice Address - Country:US
Practice Address - Phone:479-484-1011
Practice Address - Fax:479-484-1205
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127321679Medicaid
AR5C081OtherMEDICARE - GROUP NUMBER
OK100026580AMedicaid
000812852OtherUNITED CONCORDIA (INDVL)
1548288244OtherGROUP NPI
000861460OtherUNITED CONCORDIA (GRP)
ART20390Medicare UPIN
AR5C081OtherMEDICARE - GROUP NUMBER