Provider Demographics
NPI:1215594098
Name:HANCOCK, BRENNON LEWAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENNON
Middle Name:LEWAYNE
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-1978
Mailing Address - Country:US
Mailing Address - Phone:928-551-1464
Mailing Address - Fax:
Practice Address - Street 1:301 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-4712
Practice Address - Country:US
Practice Address - Phone:928-537-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0103311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice