Provider Demographics
NPI:1154657450
Name:VALLIERE, BRENDA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:M
Last Name:VALLIERE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4422
Mailing Address - Country:US
Mailing Address - Phone:260-484-5614
Mailing Address - Fax:260-484-5614
Practice Address - Street 1:1330 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4422
Practice Address - Country:US
Practice Address - Phone:260-484-5614
Practice Address - Fax:260-484-5614
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200855410OtherLEGACY PROVIDER IDENTIFICATION NUMBER
IN12008807OtherINDIANA DENTAL LICENSE NUMBER