Healthcare Provider Details

I. General information

NPI: 1447243621
Provider Name (Legal Business Name): RICHARD CARLTON BRENKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 E LAMAR RD
PHOENIX AZ
85016-1209
US

IV. Provider business mailing address

2511 E LAMAR RD
PHOENIX AZ
85016-1209
US

V. Phone/Fax

Practice location:
  • Phone: 602-977-2565
  • Fax: 602-938-4910
Mailing address:
  • Phone: 602-977-2565
  • Fax: 602-938-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4802
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: