Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | R386 | MN |
Y | 1223P0700X | Prosthodontist | D12597 | MN |
NPI | 1043488836 |
---|---|
Provider Name | Dr. Brandon D Dewitt |
First Address | Minneapolis, MN 55415-1623 |
Second Address | Minneapolis, MN 55415-1623 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2008 |
Last Update Date | 07/04/2011 |