Healthcare Provider Details

I. General information

NPI: 1942308259
Provider Name (Legal Business Name): MATTHEW TODD BRANDT DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 S MEDICAL PARK DRIVE
FISHERSVILLE VA
22939
US

IV. Provider business mailing address

54 S MEDICAL PARK DRIVE
FISHERSVILLE VA
22939
US

V. Phone/Fax

Practice location:
  • Phone: 540-886-2956
  • Fax: 540-886-2284
Mailing address:
  • Phone: 540-886-2956
  • Fax: 540-886-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401410707
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: