Provider Demographics
NPI:1801064654
Name:BRANYAN, CARL EDWARD (DDS)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:EDWARD
Last Name:BRANYAN
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:CLINICA SANTA MARIA 730 GRANDVILLE AVE S.W.
Mailing Address - Street 2:DENTAL DEPARTMENT
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-913-8401
Mailing Address - Fax:616-742-1322
Practice Address - Street 1:CLINICA SANTA MARIA 730 GRANDVILLE AVE S.W.
Practice Address - Street 2:DENTAL DEPARTMENT
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-913-8401
Practice Address - Fax:616-742-1322
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010084551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124461490Medicaid