Provider Demographics
NPI:1457871188
Name:MECKELBERG, BRANDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:MECKELBERG
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:N1838 N SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-7208
Mailing Address - Country:US
Mailing Address - Phone:920-400-9009
Mailing Address - Fax:
Practice Address - Street 1:1902 N PROSPECT AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1411
Practice Address - Country:US
Practice Address - Phone:217-408-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist