Healthcare Provider Details

I. General information

NPI: 1083901185
Provider Name (Legal Business Name): LEIGH ANN BRANDENBURG DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 N BROADWAY UNIT 606
MILWAUKEE WI
53202-5825
US

IV. Provider business mailing address

328 E 74TH ST
NEW YORK NY
10021-3708
US

V. Phone/Fax

Practice location:
  • Phone: 262-424-7148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7232-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: