Provider Demographics
NPI:1740054535
Name:VENTIMIGLIA, BRANDO
Entity type:Individual
Prefix:
First Name:BRANDO
Middle Name:
Last Name:VENTIMIGLIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22715 MARTIN RD APT 5
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1347
Mailing Address - Country:US
Mailing Address - Phone:586-224-3823
Mailing Address - Fax:
Practice Address - Street 1:38921 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-6818
Practice Address - Country:US
Practice Address - Phone:248-879-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902020373124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist