Provider Demographics
NPI:1073915039
Name:BRENT, BURTON
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:
Last Name:BRENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 WOODSIDE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2448
Mailing Address - Country:US
Mailing Address - Phone:650-851-5300
Mailing Address - Fax:650-851-5302
Practice Address - Street 1:341 GROVE DR
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7642
Practice Address - Country:US
Practice Address - Phone:650-851-5300
Practice Address - Fax:650-851-5302
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26091208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery