Provider Demographics
NPI:1295717775
Name:WALDMAN, BRENT JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JOHN
Last Name:WALDMAN
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15231 MERLINGLEN PL
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3900
Mailing Address - Country:US
Mailing Address - Phone:843-789-9738
Mailing Address - Fax:
Practice Address - Street 1:13145 KINGS LAKE DR
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3962
Practice Address - Country:US
Practice Address - Phone:843-789-9738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401410971122300000X
FLDN28891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist