Provider Demographics
NPI:1780742023
Name:CARMONY, BRENT R (MS, DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:R
Last Name:CARMONY
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 COWHORN CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:903-791-8405
Mailing Address - Fax:903-793-1046
Practice Address - Street 1:5305 COWHORN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-791-8405
Practice Address - Fax:903-793-1046
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192391223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD19239OtherBLUE CROSS BLUE SHIELD
VI105690OtherANTHEM BCBS VI
AR277330OtherUNITED CONCORDIA
AR97859OtherBLUE CROSS BLUE SHIELD AR
TX090180301Medicaid
AL900-53697OtherBCBS OF AL
AR135572679Medicaid
TN3109694OtherBCBS OF TN
TX090180302Medicaid
VI105690OtherANTHEM BCBS VI