MEDICARE: DR. BRENT RANDALL NEIDENTHAL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7642	NC

General Provider Information

NPI Number	:	1578588638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT RANDALL NEIDENTHAL D.D.S.

Provider Business Mailing Address
First Line	:	1100 HOLLY SPRINGS RD
Second Line	:	STE. 115
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9469
Country	:	US
Telephone Number	:	919-577-0017
Fax Number	:	919-577-6065

Provider Business Practice Location Address
First Line	:	1100 HOLLY SPRINGS RD
Second Line	:	STE. 115
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9469
Country	:	US
Telephone Number	:	919-577-0017
Fax Number	:	919-577-6065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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