Provider Demographics
NPI:1760566541
Name:MUNDY, BREANN MICHELE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BREANN
Middle Name:MICHELE
Last Name:MUNDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:BREANN
Other - Middle Name:MICHELE
Other - Last Name:MUNDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:10208 LANTERN RD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9705
Mailing Address - Country:US
Mailing Address - Phone:317-598-4647
Mailing Address - Fax:
Practice Address - Street 1:10208 LANTERN RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9705
Practice Address - Country:US
Practice Address - Phone:317-598-4647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010834A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist