Healthcare Provider Details

I. General information

NPI: 1679914691
Provider Name (Legal Business Name): JESSE M BRANNAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 SOUTH COLUMBIAN WAY DEPT OF VETERANS AFFAIRS PUGET SOUND HEALTH SYSTEM
SEATTLE WA
98108
US

IV. Provider business mailing address

1660 SOUTH COLUMBIAN WAY
SEATTLE WA
98108
US

V. Phone/Fax

Practice location:
  • Phone: 206-762-1010
  • Fax:
Mailing address:
  • Phone: 206-227-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE30687475
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60387475
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: