Provider Demographics
NPI:1750486684
Name:BRENT DENTAL CARE
Entity Type:Organization
Organization Name:BRENT DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:OBEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-936-2151
Mailing Address - Street 1:2939 MAIN ST
Mailing Address - Street 2:P.O. BOX 960
Mailing Address - City:BRENT
Mailing Address - State:AL
Mailing Address - Zip Code:35034-4000
Mailing Address - Country:US
Mailing Address - Phone:205-926-1901
Mailing Address - Fax:
Practice Address - Street 1:2939 MAIN ST
Practice Address - Street 2:BOX 960
Practice Address - City:BRENT
Practice Address - State:AL
Practice Address - Zip Code:35034-4000
Practice Address - Country:US
Practice Address - Phone:205-926-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOON ROAD COSMETIC & FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-14
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL 4726122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529926460Medicaid