Healthcare Provider Details

I. General information

NPI: 1366725699
Provider Name (Legal Business Name): HEIDI BRANDT, DMD,MSD,&STIG OSTERBERG, DDS, MSD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 LAWRENCE ST
PORT TOWNSEND WA
98368-6525
US

IV. Provider business mailing address

1119 LAWRENCE ST
PORT TOWNSEND WA
98368-6525
US

V. Phone/Fax

Practice location:
  • Phone: 360-385-5121
  • Fax:
Mailing address:
  • Phone: 360-385-5121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5095
License Number StateWA

VIII. Authorized Official

Name: STIG K OSTERBERG
Title or Position: OWNER
Credential: DDS, MSD
Phone: 360-385-5121