Basic Information
Provider Information | |||||||||
NPI: | 1275513475 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANNIGAN | ||||||||
FirstName: | OTIS | ||||||||
MiddleName: | ALEXANDER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT OF THE ARMY, DENTAL ACTIVITY STOP B | ||||||||
Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
City: | FORT BRAGG | ||||||||
State: | NC | ||||||||
PostalCode: | 283100001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103965610 | ||||||||
FaxNumber: | 9103967017 | ||||||||
Practice Location | |||||||||
Address1: | DEPT OF THE ARMY, DENTAL ACTIVITY STOP B | ||||||||
Address2: | 2817 REILLY RD, MCDS-NA-B | ||||||||
City: | FORT BRAGG | ||||||||
State: | NC | ||||||||
PostalCode: | 283100001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9103965610 | ||||||||
FaxNumber: | 9103967017 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 08/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 497 | VI | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | BB6932912 | 01 |   | FEDERAL DEA | OTHER |