Provider Demographics
NPI:1770835969
Name:BROSSMAN, MICHAEL A (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BROSSMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4713
Mailing Address - Country:US
Mailing Address - Phone:503-334-6761
Mailing Address - Fax:
Practice Address - Street 1:1055 N LA CANADA DR
Practice Address - Street 2:#109
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-3700
Practice Address - Country:US
Practice Address - Phone:503-334-6761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ85611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice