Healthcare Provider Details

I. General information

NPI: 1699448324
Provider Name (Legal Business Name): BRYAN DOUGLAS BRENNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 1ST AVE W STE 100
SEATTLE WA
98119-4257
US

IV. Provider business mailing address

215 1ST AVE W STE 100
SEATTLE WA
98119-4257
US

V. Phone/Fax

Practice location:
  • Phone: 206-258-4965
  • Fax:
Mailing address:
  • Phone: 206-258-4965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRYAN D BRENNER
Title or Position: DOCTOR
Credential: DDS
Phone: 206-258-4965