Provider Demographics
NPI:1831378686
Name:HUMPHREY, BRENT R (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:HUMPHREY
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 1:103 SPRING HALL DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5336
Mailing Address - Country:US
Mailing Address - Phone:843-797-2000
Mailing Address - Fax:843-797-8826
Practice Address - Street 1:103 SPRING HALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5336
Practice Address - Country:US
Practice Address - Phone:843-797-2000
Practice Address - Fax:843-797-8826
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ2872-9Medicaid