Provider Demographics
NPI:1760891717
Name:BRENTSON, RAQUEL CECILIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:CECILIA
Last Name:BRENTSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FORT BLISS DENTAC BLDG 2901 CASSIDY RD.
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79916
Mailing Address - Country:US
Mailing Address - Phone:915-742-2302
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:915-742-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20820122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist