Healthcare Provider Details

I. General information

NPI: 1235128745
Provider Name (Legal Business Name): MICHAEL JACOB BRATLAND DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 W HARVARD AVE
ROSEBURG OR
97470
US

IV. Provider business mailing address

PO BOX 1541
ROSEBURG OR
97470-0360
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-2747
  • Fax: 541-672-2757
Mailing address:
  • Phone: 541-672-2747
  • Fax: 541-672-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD8594
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: