Provider Demographics
NPI:1669729588
Name:CHURCH, BRENT WILLS (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WILLS
Last Name:CHURCH
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 1:4270 CHICKASAW RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1615
Mailing Address - Country:US
Mailing Address - Phone:901-652-0411
Mailing Address - Fax:
Practice Address - Street 1:1684 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2583
Practice Address - Country:US
Practice Address - Phone:901-254-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3659-12122300000X
KS61218122300000X, 1223P0221X
TN118921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist