Provider Demographics
NPI:1184844920
Name:SHAKESPEARE, BRENT EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:EUGENE
Last Name:SHAKESPEARE
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 1:1454 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-0118
Mailing Address - Country:US
Mailing Address - Phone:909-382-7146
Mailing Address - Fax:909-382-7101
Practice Address - Street 1:1454 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0118
Practice Address - Country:US
Practice Address - Phone:909-382-7146
Practice Address - Fax:909-382-7101
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA368721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36872OtherSTATE LICENSE NUMBER