Provider Demographics
NPI:1649358870
Name:MONFORT, BRANDT G (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDT
Middle Name:G
Last Name:MONFORT
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 1:217 SE 136TH AVE
Mailing Address - Street 2:SUITE # 102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684
Mailing Address - Country:US
Mailing Address - Phone:360-896-9595
Mailing Address - Fax:360-896-9703
Practice Address - Street 1:217 SE 136TH AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-896-9595
Practice Address - Fax:360-896-9703
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA76321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5029087Medicaid