Provider Demographics
NPI:1740494368
Name:MAXSON, BRENT CHARLES (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:CHARLES
Last Name:MAXSON
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 1:3509 SE WILLOUGHBY BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-5059
Mailing Address - Country:US
Mailing Address - Phone:772-220-2990
Mailing Address - Fax:772-220-3099
Practice Address - Street 1:3509 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5059
Practice Address - Country:US
Practice Address - Phone:772-220-2990
Practice Address - Fax:772-220-3099
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL107941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice