Provider Demographics
NPI:1801124789
Name:BRANDON KENT FARRELL DDS PA II
Entity type:Organization
Organization Name:BRANDON KENT FARRELL DDS PA II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-508-2346
Mailing Address - Street 1:1300 BRIDGE BARRIER RD
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-3938
Mailing Address - Country:US
Mailing Address - Phone:910-458-9401
Mailing Address - Fax:910-458-3495
Practice Address - Street 1:1300 BRIDGE BARRIER RD
Practice Address - Street 2:
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3938
Practice Address - Country:US
Practice Address - Phone:910-458-9401
Practice Address - Fax:910-458-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83161223G0001X
NC45921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997952Medicaid