Provider Demographics
NPI:1962627240
Name:JONES, BRENT C
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:C
Last Name:JONES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ASTRO LN NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-9022
Mailing Address - Country:US
Mailing Address - Phone:509-766-8455
Mailing Address - Fax:
Practice Address - Street 1:1336 E HUNTER PL
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2449
Practice Address - Country:US
Practice Address - Phone:509-766-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006476122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist