Provider Demographics
NPI:1780990655
Name:OWEN WILBANKS, BRANDI ALLISON
Entity type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:ALLISON
Last Name:OWEN WILBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:BRANDI
Other - Middle Name:ALLISON
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-0459
Mailing Address - Country:US
Mailing Address - Phone:706-894-1919
Mailing Address - Fax:
Practice Address - Street 1:157 HODGES ST
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-3295
Practice Address - Country:US
Practice Address - Phone:706-894-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0140921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice