Provider Demographics
NPI:1811450943
Name:COOLBAUGH, BRENNA EILEEN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENNA
Middle Name:EILEEN
Last Name:COOLBAUGH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 GARDEN GATE LN
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-0257
Mailing Address - Country:US
Mailing Address - Phone:919-604-7293
Mailing Address - Fax:
Practice Address - Street 1:12501 NORWALK BLVD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2042
Practice Address - Country:US
Practice Address - Phone:562-929-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-06
Last Update Date:2023-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0425811223G0001X
390200000X
CA1076531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program