Provider Demographics
NPI:1043748049
Name:WOOD, BRANDON B (DMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:B
Last Name:WOOD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-2181
Mailing Address - Country:US
Mailing Address - Phone:847-395-6166
Mailing Address - Fax:
Practice Address - Street 1:1326 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-2181
Practice Address - Country:US
Practice Address - Phone:847-395-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-02
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist