Provider Demographics
NPI:1043365455
Name:ROMBERG, BRENT PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:PATRICK
Last Name:ROMBERG
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 1:8116 112TH STREET CT E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-7816
Mailing Address - Country:US
Mailing Address - Phone:253-848-5033
Mailing Address - Fax:253-770-2808
Practice Address - Street 1:8116 112TH STREET CT E
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7816
Practice Address - Country:US
Practice Address - Phone:253-848-5033
Practice Address - Fax:253-770-2808
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000082151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice