1871849927 NPI number — HEIDI MARIE BRANDENBURG DDS

Table of content: HEIDI MARIE BRANDENBURG DDS (NPI 1871849927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871849927 NPI number — HEIDI MARIE BRANDENBURG DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDENBURG
Provider First Name:
HEIDI
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871849927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3948 W 50TH ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55424-1210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-922-8787
Provider Business Mailing Address Fax Number:
952-922-5595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3948 W 50TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55424-1210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-922-8787
Provider Business Practice Location Address Fax Number:
952-922-5595
Provider Enumeration Date:
07/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D10348 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 78956BR . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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