Provider Demographics
NPI:1649370339
Name:DEPTA, BRENT (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:DEPTA
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 1:2711 WINDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1696
Mailing Address - Country:US
Mailing Address - Phone:229-247-0437
Mailing Address - Fax:229-242-4395
Practice Address - Street 1:2711 WINDEMERE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1696
Practice Address - Country:US
Practice Address - Phone:229-247-0437
Practice Address - Fax:229-242-4395
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics