Provider Demographics
NPI:1164500591
Name:MARK BRODHAGEN DDS SC
Entity Type:Organization
Organization Name:MARK BRODHAGEN DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BRODHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-499-2121
Mailing Address - Street 1:1052 BEL AIRE COURT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-499-2121
Mailing Address - Fax:920-499-7644
Practice Address - Street 1:1052 BEL AIRE COURT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-499-2121
Practice Address - Fax:920-499-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty