Provider Demographics
NPI:1114385317
Name:BRENNER, BARRY I (DDS)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:I
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3540
Mailing Address - Country:US
Mailing Address - Phone:215-389-7982
Mailing Address - Fax:215-389-7966
Practice Address - Street 1:2340 S 12TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3540
Practice Address - Country:US
Practice Address - Phone:215-389-7982
Practice Address - Fax:215-389-7966
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-023108-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice