Provider Demographics
NPI:1013312289
Name:BRENT DAVID POWELL DMD INC
Entity type:Organization
Organization Name:BRENT DAVID POWELL DMD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:558-299-3949
Mailing Address - Street 1:7005 N CHESTNUT AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0348
Mailing Address - Country:US
Mailing Address - Phone:559-299-3949
Mailing Address - Fax:559-299-7880
Practice Address - Street 1:7005 N CHESTNUT AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0348
Practice Address - Country:US
Practice Address - Phone:559-299-3949
Practice Address - Fax:559-299-7880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA561481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty