Provider Demographics
NPI:1144758574
Name:HUMPHREYS, BRENNAN KANE
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:KANE
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 WATAUGA ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4429
Mailing Address - Country:US
Mailing Address - Phone:423-707-2999
Mailing Address - Fax:
Practice Address - Street 1:613 WATAUGA ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4429
Practice Address - Country:US
Practice Address - Phone:423-707-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN105331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry