Provider Demographics
NPI:1063557643
Name:GREGORY C. BRANDT, DDS, PC
Entity type:Organization
Organization Name:GREGORY C. BRANDT, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-964-1490
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-0547
Mailing Address - Country:US
Mailing Address - Phone:515-964-1490
Mailing Address - Fax:515-965-5603
Practice Address - Street 1:907 N. ANKENY BLVD.
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023
Practice Address - Country:US
Practice Address - Phone:515-964-1490
Practice Address - Fax:515-965-5603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA69621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA514194Medicaid