Provider Demographics
NPI:1831745587
Name:VILLAR, BRANDON ADAM
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ADAM
Last Name:VILLAR
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 1:2874 KING ST SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3593
Mailing Address - Country:US
Mailing Address - Phone:770-435-7358
Mailing Address - Fax:
Practice Address - Street 1:2874 KING ST SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3593
Practice Address - Country:US
Practice Address - Phone:770-435-7358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist