Provider Demographics
NPI:1265442073
Name:PRENTICE, BRIAN ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANDREW
Last Name:PRENTICE
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 1:14831 W 159TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9008
Mailing Address - Country:US
Mailing Address - Phone:630-324-5369
Mailing Address - Fax:815-744-7059
Practice Address - Street 1:14831 W 159TH ST STE 1
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60491-9008
Practice Address - Country:US
Practice Address - Phone:630-324-5369
Practice Address - Fax:815-744-7059
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0313991223G0001X
CO9334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
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