Provider Demographics
NPI:1639482896
Name:HIEBERT, BRENT MICHAEL (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MICHAEL
Last Name:HIEBERT
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 NE HIGHWAY 99W STE A
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6261
Mailing Address - Country:US
Mailing Address - Phone:503-883-7668
Mailing Address - Fax:503-883-7669
Practice Address - Street 1:2090 NE HIGHWAY 99W STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6261
Practice Address - Country:US
Practice Address - Phone:503-883-7668
Practice Address - Fax:503-883-7669
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59374122300000X
ORD105691223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist