Provider Demographics
NPI:1013257930
Name:DR MICHAEL BRENNAN D.M.D.
Entity type:Organization
Organization Name:DR MICHAEL BRENNAN D.M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-344-5511
Mailing Address - Street 1:128 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-3327
Mailing Address - Country:US
Mailing Address - Phone:570-344-5511
Mailing Address - Fax:
Practice Address - Street 1:128 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504-3327
Practice Address - Country:US
Practice Address - Phone:570-344-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026290-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011290720001OtherMEDICAL ASSISTANCE