MEDICARE: MARK ANDREW BRODHAGEN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1338G	WI
2	332B00000X	Durable Medical Equipment & Medical Supplies	1338G	WI

General Provider Information

NPI Number	:	1760468136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ANDREW BRODHAGEN DDS

Provider Business Mailing Address
First Line	:	1052 BEL AIRE CT
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5015
Country	:	US
Telephone Number	:	920-499-2121
Fax Number	:	920-499-7644

Provider Business Practice Location Address
First Line	:	1052 BEL AIRE CT
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5015
Country	:	US
Telephone Number	:	920-499-2121
Fax Number	:	920-499-7644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	04/13/2026

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