Provider Demographics
NPI:1437475704
Name:BRANNICK D ADAMS DDS PC
Entity Type:Organization
Organization Name:BRANNICK D ADAMS DDS PC
Other - Org Name:HARVARD DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANNICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-673-5150
Mailing Address - Street 1:1539 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2873
Mailing Address - Country:US
Mailing Address - Phone:541-673-5150
Mailing Address - Fax:
Practice Address - Street 1:1539 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2873
Practice Address - Country:US
Practice Address - Phone:541-673-5150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR85901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213541Medicaid