Provider Demographics
NPI:1891939484
Name:BRACKETT, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4715
Mailing Address - Country:US
Mailing Address - Phone:207-807-1692
Mailing Address - Fax:207-591-5108
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4715
Practice Address - Country:US
Practice Address - Phone:207-807-1692
Practice Address - Fax:207-591-5108
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist