MEDICARE: DR. BRETT MICHAEL QUACKENBUSH DDS, MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	D4963	AZ

General Provider Information

NPI Number	:	1669408472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRETT MICHAEL QUACKENBUSH DDS, MSD

Provider Business Mailing Address
First Line	:	1534 E RAY RD
Second Line	:	#121
City	:	GILBERT
State	:	AZ
Zip	:	85296-4429
Country	:	US
Telephone Number	:	480-963-8373
Fax Number	:	480-963-4489

Provider Business Practice Location Address
First Line	:	1534 E RAY RD
Second Line	:	#121
City	:	GILBERT
State	:	AZ
Zip	:	85296-4429
Country	:	US
Telephone Number	:	480-963-8373
Fax Number	:	480-963-4489

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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