Healthcare Provider Details

I. General information

NPI: 1740267517
Provider Name (Legal Business Name): MICHAEL RODERICK BRENYO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 557, BOX 1207
FPO AP
96379-1207
JP

IV. Provider business mailing address

PSC 557, BOX 1207
FPO AP
96379-1207
JP

V. Phone/Fax

Practice location:
  • Phone: 011816117468298
  • Fax:
Mailing address:
  • Phone: 011816117468298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number10387
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS024094L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0401008419
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: