Provider Demographics
NPI:1235211129
Name:BOYETT, BRENT EDGEWORTH (DMD, DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:EDGEWORTH
Last Name:BOYETT
Suffix:
Gender:M
Credentials:DMD, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 MILITARY ST S
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:AL
Mailing Address - Zip Code:35570-6651
Mailing Address - Country:US
Mailing Address - Phone:205-921-0893
Mailing Address - Fax:205-921-6723
Practice Address - Street 1:2131 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-6651
Practice Address - Country:US
Practice Address - Phone:205-921-5556
Practice Address - Fax:205-921-5595
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL46221223G0001X
ALDO654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009981160Medicaid
AL009981160Medicaid