Provider Demographics
NPI:1932404175
Name:HEIDI BRANDT DMD MSD & STIG K OSTERBERG DDS MSD, PC
Entity Type:Organization
Organization Name:HEIDI BRANDT DMD MSD & STIG K OSTERBERG DDS MSD, PC
Other - Org Name:OLYMPIC PENINSULA IMPLANTS & PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STIG
Authorized Official - Middle Name:KJELL
Authorized Official - Last Name:OSTERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:360-385-5121
Mailing Address - Street 1:1119 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6525
Mailing Address - Country:US
Mailing Address - Phone:360-385-5121
Mailing Address - Fax:360-379-9534
Practice Address - Street 1:624 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6224
Practice Address - Country:US
Practice Address - Phone:360-452-7482
Practice Address - Fax:360-457-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000050951223P0300X
WADE000053471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000200299Medicare PIN