Provider Demographics
NPI:1942308259
Name:BRANDT, MATTHEW TODD (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TODD
Last Name:BRANDT
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 S MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939
Mailing Address - Country:US
Mailing Address - Phone:540-886-2956
Mailing Address - Fax:540-886-2284
Practice Address - Street 1:54 S MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939
Practice Address - Country:US
Practice Address - Phone:540-886-2956
Practice Address - Fax:540-886-2284
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9198564Medicaid