Basic Information
Provider Information
NPI: 1295371425
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NESTMAN
FirstName: BRETT
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 106 BAMBERGER WAY
Address2:  
City: CENTERVILLE
State: UT
PostalCode: 840142804
CountryCode: US
TelephoneNumber: 8017125497
FaxNumber:  
Practice Location
Address1: 1600 WEEOT WAY
Address2:  
City: ARCATA
State: CA
PostalCode: 955214734
CountryCode: US
TelephoneNumber: 7078255040
FaxNumber: 7078256747
Other Information
ProviderEnumerationDate: 11/22/2019
LastUpdateDate: 08/08/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/08/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X11429508-9921UTY Dental ProvidersDentist 

No ID Information.


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