Provider Demographics
NPI:1902152887
Name:BRENNER, JORDAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:M
Last Name:BRENNER
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 1:1359 N 205TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-3215
Mailing Address - Country:US
Mailing Address - Phone:206-533-9693
Mailing Address - Fax:206-533-9691
Practice Address - Street 1:1359 N 205TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3215
Practice Address - Country:US
Practice Address - Phone:206-533-9693
Practice Address - Fax:206-533-9691
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-09972122300000X
WADE60291757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist