Provider Demographics
NPI:1033384466
Name:POWELL, BRENT DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DAVID
Last Name:POWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5656 E LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-9519
Mailing Address - Country:US
Mailing Address - Phone:216-543-5178
Mailing Address - Fax:
Practice Address - Street 1:5656 E LEBANON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-9519
Practice Address - Country:US
Practice Address - Phone:216-543-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist