Provider Demographics
NPI:1750563342
Name:PHILLIP MARVIN BRAME DDS MS PA
Entity type:Organization
Organization Name:PHILLIP MARVIN BRAME DDS MS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:BRAME
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:336-667-1254
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:1419 WEST D ST
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1367
Mailing Address - Country:US
Mailing Address - Phone:336-667-1254
Mailing Address - Fax:336-667-1255
Practice Address - Street 1:1419 WEST D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-1367
Practice Address - Country:US
Practice Address - Phone:336-667-1254
Practice Address - Fax:336-667-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39871223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8991034Medicaid