Provider Demographics
NPI:1295014660
Name:BRENT E AGRAN, DDS, LLC
Entity Type:Organization
Organization Name:BRENT E AGRAN, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:AGRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-372-5245
Mailing Address - Street 1:1081 N MARSHFIELD AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3836
Mailing Address - Country:US
Mailing Address - Phone:847-372-5245
Mailing Address - Fax:
Practice Address - Street 1:5850 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-3202
Practice Address - Country:US
Practice Address - Phone:773-561-2237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027610122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty