Healthcare Provider Details

I. General information

NPI: 1760468136
Provider Name (Legal Business Name): MARK ANDREW BRODHAGEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 BEL AIRE CT
GREEN BAY WI
54304-5015
US

IV. Provider business mailing address

1052 BEL AIRE CT
GREEN BAY WI
54304-5015
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-2121
  • Fax: 920-499-7644
Mailing address:
  • Phone: 920-499-2121
  • Fax: 920-499-7644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1338G
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1338G
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: