Provider Demographics
NPI:1093705592
Name:BRANDT, THOMAS GEORGE (DDS SC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GEORGE
Last Name:BRANDT
Suffix:
Gender:M
Credentials:DDS SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 WISCONSIN AVE
Mailing Address - Street 2:PO BOX 175
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-1316
Mailing Address - Country:US
Mailing Address - Phone:920-898-4110
Mailing Address - Fax:920-898-5995
Practice Address - Street 1:2011 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1316
Practice Address - Country:US
Practice Address - Phone:920-898-4110
Practice Address - Fax:920-898-5995
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2122G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist