Provider Demographics
NPI:1558441576
Name:BRENNAN, MICHAEL T (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:BRENNAN
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 ABBEY PL
Practice Address - Street 2:STE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3835
Practice Address - Country:US
Practice Address - Phone:704-512-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7254122300000X, 125Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No125Q00000XDental ProvidersOral Medicinist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1558441576Medicaid
NC899017YMedicaid
NC899017YMedicaid
NC1558441576Medicaid