Provider Demographics
NPI:1942520655
Name:PENLY, BRIAN B (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:B
Last Name:PENLY
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 1:3549 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-5641
Mailing Address - Country:US
Mailing Address - Phone:712-328-0708
Mailing Address - Fax:712-328-8991
Practice Address - Street 1:3549 11TH AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-5641
Practice Address - Country:US
Practice Address - Phone:712-328-0708
Practice Address - Fax:712-328-8991
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08708122300000X
NE6888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist