MEDICARE: DR. BRENNAN BISH DDS

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	122300000X	Dentist	4480	WV

General Provider Information

NPI Number	:	1790303931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENNAN BISH DDS

Provider Business Mailing Address
First Line	:	113 SOUTHBROOKE DR
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-9070
Country	:	US
Telephone Number	:	304-550-9311
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 KINETIC DR
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-5270
Country	:	US
Telephone Number	:	304-781-8600
Fax Number	:

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

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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