Healthcare Provider Details

I. General information

NPI: 1174198550
Provider Name (Legal Business Name): BRANDON MICHAEL DENNIS I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 3RD AVE
SEATTLE WA
98104-2304
US

IV. Provider business mailing address

515 3RD AVE
SEATTLE WA
98104-2304
US

V. Phone/Fax

Practice location:
  • Phone: 206-464-1570
  • Fax:
Mailing address:
  • Phone: 206-464-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61178497
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: