Provider Demographics
NPI:1477548014
Name:MCCLENNY, BRENT S (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:S
Last Name:MCCLENNY
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 1:626 QUAIL RUN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3142
Mailing Address - Country:US
Mailing Address - Phone:618-207-9694
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL39541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice