Provider Demographics
NPI:1598370199
Name:VEST, BRENDA JO
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JO
Last Name:VEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1917
Mailing Address - Country:US
Mailing Address - Phone:765-641-7499
Mailing Address - Fax:
Practice Address - Street 1:1518 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-2021
Practice Address - Country:US
Practice Address - Phone:765-552-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13006667A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist