Healthcare Provider Details

I. General information

NPI: 1659613115
Provider Name (Legal Business Name): BRANDI BERLAND R.D.H., LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11216 61ST ST
KENOSHA WI
53142-7261
US

IV. Provider business mailing address

11216 61ST ST
KENOSHA WI
53142-7261
US

V. Phone/Fax

Practice location:
  • Phone: 262-764-5237
  • Fax:
Mailing address:
  • Phone: 262-764-5237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9824-16
License Number StateWI

VIII. Authorized Official

Name: MRS. BRANDI LYNN BERLAND
Title or Position: REGISTERED DENTAL HYGIENIST
Credential: R.D.H
Phone: 414-403-7181