Provider Demographics
NPI:1225199508
Name:DIMMITT, BRANDI J (DDS)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:J
Last Name:DIMMITT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S VISITING EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:NIOBRARA
Mailing Address - State:NE
Mailing Address - Zip Code:68760-7201
Mailing Address - Country:US
Mailing Address - Phone:402-857-2300
Mailing Address - Fax:
Practice Address - Street 1:110 S VISITING EAGLE ST
Practice Address - Street 2:
Practice Address - City:NIOBRARA
Practice Address - State:NE
Practice Address - Zip Code:68760-7201
Practice Address - Country:US
Practice Address - Phone:402-857-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE60691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025439300Medicaid