Provider Demographics
NPI:1033137344
Name:BRANDT, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:BRANDT
Suffix:
Gender:M
Credentials:
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 547
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-0547
Mailing Address - Country:US
Mailing Address - Phone:515-964-1490
Mailing Address - Fax:515-965-5603
Practice Address - Street 1:907 N. ANKENY BLVD.
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1711
Practice Address - Country:US
Practice Address - Phone:515-964-1490
Practice Address - Fax:515-965-5603
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA69621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0216499Medicaid
IA514194OtherTRICARE