Provider Demographics
NPI:1407003650
Name:BETHERS, BRENT H (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:H
Last Name:BETHERS
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 1:20738 W LEGEND TRL
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-1670
Mailing Address - Country:US
Mailing Address - Phone:626-376-7987
Mailing Address - Fax:
Practice Address - Street 1:20738 W LEGEND TRL
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396
Practice Address - Country:US
Practice Address - Phone:626-376-7987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0102331223S0112X
CA574711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586884Medicaid