Provider Demographics
NPI:1780683094
Name:BEVINS, BRENT (DMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BEVINS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 GREENUP ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3256
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:859-655-6125
Practice Address - Street 1:1132 GREENUP ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3256
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:859-655-6125
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60044351Medicaid