Provider Demographics
NPI:1225132871
Name:BAILEY, BRENT G (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:G
Last Name:BAILEY
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 1:15 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2384
Mailing Address - Country:US
Mailing Address - Phone:843-886-6461
Mailing Address - Fax:843-886-3957
Practice Address - Street 1:15 21ST AVE
Practice Address - Street 2:
Practice Address - City:ISLE OF PALMS
Practice Address - State:SC
Practice Address - Zip Code:29451-2384
Practice Address - Country:US
Practice Address - Phone:843-886-6461
Practice Address - Fax:846-886-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3539Medicaid
201548345Medicare UPIN