Provider Demographics
NPI:1225417249
Name:POPOVICH, BRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:POPOVICH
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 1:157 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-3346
Mailing Address - Country:US
Mailing Address - Phone:716-693-0232
Mailing Address - Fax:
Practice Address - Street 1:157 MAIN ST
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-3346
Practice Address - Country:US
Practice Address - Phone:716-693-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059066122300000X
MADN1857131122300000X
FLDN22281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist