Provider Demographics
NPI:1003654492
Name:BRANT, COLLIN C (DDS)
Entity type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:C
Last Name:BRANT
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 W HURON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-6357
Mailing Address - Country:US
Mailing Address - Phone:713-805-5488
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE # MC160
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0354131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program