Provider Demographics
NPI:1689914061
Name:BRANDON M. BRAUD, DDS, LLC
Entity Type:Organization
Organization Name:BRANDON M. BRAUD, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-289-2831
Mailing Address - Street 1:7230 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-1735
Mailing Address - Country:US
Mailing Address - Phone:303-289-2831
Mailing Address - Fax:720-502-7029
Practice Address - Street 1:7230 LOCUST ST
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-1735
Practice Address - Country:US
Practice Address - Phone:303-289-2831
Practice Address - Fax:720-502-7029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00201827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24389862Medicaid