Basic Information
| Provider Information | |||||||||
| NPI: | 1609397389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 S ROLLIE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038926401 | ||||||||
| FaxNumber: | 3032864589 | ||||||||
| Practice Location | |||||||||
| Address1: | 19725 HIGHWAY 59 N | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773383566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819728000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2017 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00204293 | CO | Y | Dental Providers | Dentist | 1223G0001X | 33090 | TX | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 33090 | 01 | TX | TEXAS STATE BOARD OF DENTAL EXAMINERS | OTHER |