Provider Demographics
NPI:1538998562
Name:BRANNON, DANICA
Entity type:Individual
Prefix:
First Name:DANICA
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 101ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2669
Mailing Address - Country:US
Mailing Address - Phone:612-965-3096
Mailing Address - Fax:
Practice Address - Street 1:1790 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-3419
Practice Address - Country:US
Practice Address - Phone:651-735-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH11617124Q00000X
MNDT173125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist