Provider Demographics
NPI:1255123261
Name:MAI, BRANDON TIEN
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:TIEN
Last Name:MAI
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11784 TREADWELL DR
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-6122
Mailing Address - Country:US
Mailing Address - Phone:858-761-6742
Mailing Address - Fax:
Practice Address - Street 1:11784 TREADWELL DR
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-6122
Practice Address - Country:US
Practice Address - Phone:858-761-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14223194-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist