Provider Demographics
NPI:1568461200
Name:BACH, BRENT CUSHING (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:CUSHING
Last Name:BACH
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 1:7265 PORTAGE ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-7826
Mailing Address - Country:US
Mailing Address - Phone:330-498-9730
Mailing Address - Fax:330-498-9753
Practice Address - Street 1:7265 PORTAGE ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-7826
Practice Address - Country:US
Practice Address - Phone:330-498-9730
Practice Address - Fax:330-498-9753
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH211691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH030446553028Medicaid
OH2248606Medicaid