Healthcare Provider Details

I. General information

NPI: 1619174877
Provider Name (Legal Business Name): BRANDON E NEWELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 DEVELOPMENT DR
GREEN BAY WI
54311-4247
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-347-0400
  • Fax:
Mailing address:
  • Phone: 920-490-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number08480
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS70
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE 60277199
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1001664
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: