Provider Demographics
NPI:1407289457
Name:BRANCHEAU, BRIAN MICHAEL (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:BRANCHEAU
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 194TH ST SW STE 209
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4613
Mailing Address - Country:US
Mailing Address - Phone:206-422-5083
Mailing Address - Fax:
Practice Address - Street 1:4100 194TH ST SW STE 209
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4613
Practice Address - Country:US
Practice Address - Phone:206-422-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60306318122300000X
WADE603063181223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist