Provider Demographics
NPI:1477616050
Name:BRETTIN, BRYAN THOMAS (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:THOMAS
Last Name:BRETTIN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 2ND ST S STE 230
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1980
Mailing Address - Country:US
Mailing Address - Phone:715-377-2155
Mailing Address - Fax:715-377-2157
Practice Address - Street 1:400 2ND ST S STE 230
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1980
Practice Address - Country:US
Practice Address - Phone:715-377-2155
Practice Address - Fax:715-377-2157
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60950151223X0400X
MND116441223X0400X
ND19781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics