Provider Demographics
NPI:1851709331
Name:HAZLEWOOD, BRENT MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MICHAEL
Last Name:HAZLEWOOD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12662 RILEY ST STE 130
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8023
Mailing Address - Country:US
Mailing Address - Phone:616-399-6811
Mailing Address - Fax:616-399-6812
Practice Address - Street 1:12662 RILEY ST STE 130
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8023
Practice Address - Country:US
Practice Address - Phone:616-399-6811
Practice Address - Fax:616-399-6812
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010211931223E0200X, 122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist