Provider Demographics
NPI:1023135704
Name:BRANDON, ROGER (DDS)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:BRANDON
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 1:12991 POTRANCO RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-7105
Mailing Address - Country:US
Mailing Address - Phone:210-455-1110
Mailing Address - Fax:210-455-1150
Practice Address - Street 1:12991 POTRANCO RD STE 107
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-7105
Practice Address - Country:US
Practice Address - Phone:210-455-1110
Practice Address - Fax:210-455-1150
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist