Provider Demographics
NPI:1710127378
Name:BRENDA COPELAND DDS PA
Entity Type:Organization
Organization Name:BRENDA COPELAND DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:02/29/1960
Authorized Official - Phone:903-753-7515
Mailing Address - Street 1:723 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5412
Mailing Address - Country:US
Mailing Address - Phone:903-753-7515
Mailing Address - Fax:903-753-0003
Practice Address - Street 1:723 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5412
Practice Address - Country:US
Practice Address - Phone:903-753-7515
Practice Address - Fax:903-753-0003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENDA COPELAND DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16043261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherDENTIST