Provider Demographics
NPI:1750482808
Name:DEVITO, BRANDON ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:ERIC
Last Name:DEVITO
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 1:20 MEDICAL CAMPUS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4096
Mailing Address - Country:US
Mailing Address - Phone:910-755-6788
Mailing Address - Fax:910-755-6789
Practice Address - Street 1:20 MEDICAL CAMPUS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4096
Practice Address - Country:US
Practice Address - Phone:910-755-6788
Practice Address - Fax:910-755-6789
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900372Medicaid