Provider Demographics
NPI:1720125230
Name:SCHVANEVELDT, BRENT TRACY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:TRACY
Last Name:SCHVANEVELDT
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:PO BOX 837
Mailing Address - Street 2:P.O. BOX 837
Mailing Address - City:ABERDEEN
Mailing Address - State:ID
Mailing Address - Zip Code:83210-0837
Mailing Address - Country:US
Mailing Address - Phone:208-397-4198
Mailing Address - Fax:208-397-5606
Practice Address - Street 1:81 WEST WASHINGTON
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:ID
Practice Address - Zip Code:83210
Practice Address - Country:US
Practice Address - Phone:208-397-4419
Practice Address - Fax:208-397-5606
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-16141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice