Provider Demographics
NPI:1528066800
Name:ZETTERBERG, BRIAN EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EDWARD
Last Name:ZETTERBERG
Suffix:
Gender:M
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:PO BOX 1240
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-1240
Mailing Address - Country:US
Mailing Address - Phone:360-297-1847
Mailing Address - Fax:360-297-3481
Practice Address - Street 1:8208 NE STATE HIGHWAY 104
Practice Address - Street 2:SUITE 104
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-8430
Practice Address - Country:US
Practice Address - Phone:360-297-1847
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist