Provider Demographics
NPI:1790993376
Name:BRANDON C. PAYNE D.D.S., M.D., P.C.
Entity Type:Organization
Organization Name:BRANDON C. PAYNE D.D.S., M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:719-542-4546
Mailing Address - Street 1:4728 EAGLERIDGE CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2196
Mailing Address - Country:US
Mailing Address - Phone:719-542-4546
Mailing Address - Fax:719-542-4548
Practice Address - Street 1:4728 EAGLERIDGE CIR STE 110
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2196
Practice Address - Country:US
Practice Address - Phone:719-542-4546
Practice Address - Fax:719-542-4548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33987220Medicaid