Provider Demographics
NPI:1275384463
Name:WILLE, BRENDAN
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:WILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 SADDLEBACK WAY
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-1828
Mailing Address - Country:US
Mailing Address - Phone:443-987-8422
Mailing Address - Fax:
Practice Address - Street 1:51 E 125TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1685
Practice Address - Country:US
Practice Address - Phone:646-827-9819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty