Basic Information
| Provider Information | |||||||||
| NPI: | 1245350693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSON | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 E MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 E MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094885256 | ||||||||
| FaxNumber: | 5094889939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE00010850 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0218526 | 01 | WA | WA STATE D L&I # | OTHER |