Provider Demographics
NPI:1699448324
Name:BRYAN DOUGLAS BRENNER
Entity type:Organization
Organization Name:BRYAN DOUGLAS BRENNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-258-4965
Mailing Address - Street 1:215 1ST AVE W STE 100
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-4257
Mailing Address - Country:US
Mailing Address - Phone:206-258-4965
Mailing Address - Fax:
Practice Address - Street 1:215 1ST AVE W STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4257
Practice Address - Country:US
Practice Address - Phone:206-258-4965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-28
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No122300000XDental ProvidersDentistGroup - Multi-Specialty