Healthcare Provider Details

I. General information

NPI: 1548543374
Provider Name (Legal Business Name): BRETT NYDEGGER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

509 OLIVE WAY SUITE 637
SEATTLE WA
98101
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-5399
  • Fax:
Mailing address:
  • Phone: 206-624-5115
  • Fax: 206-623-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE60366761
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: