Provider Demographics
NPI:1376855098
Name:PARKER, BRENT DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DAVID
Last Name:PARKER
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 1:1213 CLIFFVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2003
Mailing Address - Country:US
Mailing Address - Phone:608-492-0478
Mailing Address - Fax:
Practice Address - Street 1:940 FRONTENAC DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-6588
Practice Address - Country:US
Practice Address - Phone:507-494-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6545-0151223G0001X
WI64545-151223G0001X
MND14811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice