Provider Demographics
NPI:1972524908
Name:UNDERWOOD, BRIAN JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:UNDERWOOD
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 1:105 5TH AVE N
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:STRUM
Mailing Address - State:WI
Mailing Address - Zip Code:54770-9252
Mailing Address - Country:US
Mailing Address - Phone:715-695-2918
Mailing Address - Fax:715-695-3852
Practice Address - Street 1:105 5TH AVE N
Practice Address - Street 2:
Practice Address - City:STRUM
Practice Address - State:WI
Practice Address - Zip Code:54770-9252
Practice Address - Country:US
Practice Address - Phone:715-695-2918
Practice Address - Fax:715-695-3852
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33693400Medicaid
391675083011OtherBLUE CROSS BLUE SHIELD
391675083001OtherDELTA DENTAL