Provider Demographics
NPI:1043797178
Name:SORENSEN, BRACKEN (DMD)
Entity Type:Individual
Prefix:
First Name:BRACKEN
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:DMD
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 2314
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-2314
Mailing Address - Country:US
Mailing Address - Phone:509-438-8840
Mailing Address - Fax:
Practice Address - Street 1:181 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2801
Practice Address - Country:US
Practice Address - Phone:509-684-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-21
Last Update Date:2018-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608575811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice