=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679914691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE M BRANNAN D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2013
-----------------------------------------------------
Last Update Date | 10/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 SOUTH COLUMBIAN WAY DEPT OF VETERANS AFFAIRS PUGET SOUND HEALTH SYSTEM
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-762-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1660 SOUTH COLUMBIAN WAY
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-227-2933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE60387475
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE30687475
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------