Provider Demographics
NPI:1598161127
Name:BRENNER, CAROL (RDH)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:LOGSDON BRENNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:3312 ELLIS WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1944
Mailing Address - Country:US
Mailing Address - Phone:502-458-9420
Mailing Address - Fax:
Practice Address - Street 1:3312 ELLIS WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1944
Practice Address - Country:US
Practice Address - Phone:502-458-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0900124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist