Provider Demographics
NPI:1861683112
Name:PACK, BRETT L (DMD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:L
Last Name:PACK
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 1:9039 CASTLEWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8217
Mailing Address - Country:US
Mailing Address - Phone:509-765-0870
Mailing Address - Fax:509-765-0870
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1893
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:509-766-8993
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 00011081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist