Provider Demographics
NPI:1952044208
Name:WHEELER, BRENT (DMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WHEELER
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 1:6160 S RED FOX CIR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-3718
Mailing Address - Country:US
Mailing Address - Phone:760-608-3993
Mailing Address - Fax:
Practice Address - Street 1:2275 S EAGLE RD STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5075
Practice Address - Country:US
Practice Address - Phone:208-215-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12795233-99221223G0001X
IDD-54001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice