Provider Demographics
NPI:1609289073
Name:JORDAN BRENNER DDS, PLLC
Entity Type:Organization
Organization Name:JORDAN BRENNER DDS, PLLC
Other - Org Name:BRIGHT 32
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:MCDONALD
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:563-271-9529
Mailing Address - Street 1:1359 N 205TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-3215
Mailing Address - Country:US
Mailing Address - Phone:206-533-9693
Mailing Address - Fax:206-533-9691
Practice Address - Street 1:1359 N 205TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3215
Practice Address - Country:US
Practice Address - Phone:206-533-9693
Practice Address - Fax:206-533-9691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602917571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty