Provider Demographics
NPI:1760468136
Name:BRODHAGEN, MARK ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:BRODHAGEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 BEL AIRE CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5015
Mailing Address - Country:US
Mailing Address - Phone:920-499-2121
Mailing Address - Fax:920-499-7644
Practice Address - Street 1:1052 BEL AIRE CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5015
Practice Address - Country:US
Practice Address - Phone:920-499-2121
Practice Address - Fax:920-499-7644
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1338G332BC3200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment