Provider Demographics
NPI:1538428909
Name:PENAZ, BRANDON JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JAMES
Last Name:PENAZ
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 1:8775 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9634
Mailing Address - Country:US
Mailing Address - Phone:952-239-2664
Mailing Address - Fax:
Practice Address - Street 1:8775 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-9634
Practice Address - Country:US
Practice Address - Phone:952-239-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist