Provider Demographics
NPI:1215016829
Name:INGRAM, BRENT THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:THOMAS
Last Name:INGRAM
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 1:5149 MOORPARK AVE
Mailing Address - Street 2:# 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129
Mailing Address - Country:US
Mailing Address - Phone:408-996-9393
Mailing Address - Fax:408-996-3034
Practice Address - Street 1:5149 MOORPARK AVE
Practice Address - Street 2:# 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-996-9393
Practice Address - Fax:408-996-3034
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA439781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice