Provider Demographics
NPI:1902981921
Name:BRANDNER, CRAIG J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:J
Last Name:BRANDNER
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 1:100 LAFITTE ALY
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-2716
Mailing Address - Country:US
Mailing Address - Phone:985-643-7455
Mailing Address - Fax:
Practice Address - Street 1:2364 GAUSE BLVD E
Practice Address - Street 2:SUITE 102
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4141
Practice Address - Country:US
Practice Address - Phone:985-847-0104
Practice Address - Fax:985-847-0118
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA39091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAT98200Medicare UPIN
LA58292Medicare ID - Type Unspecified