Healthcare Provider Details

I. General information

NPI: 1013312289
Provider Name (Legal Business Name): BRENT DAVID POWELL DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 N CHESTNUT AVE SUITE 101
FRESNO CA
93720-0348
US

IV. Provider business mailing address

7005 N CHESTNUT AVE SUITE 101
FRESNO CA
93720-0348
US

V. Phone/Fax

Practice location:
  • Phone: 559-299-3949
  • Fax: 559-299-7880
Mailing address:
  • Phone: 559-299-3949
  • Fax: 559-299-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number56148
License Number StateCA

VIII. Authorized Official

Name: DR. BRENT DAVID POWELL
Title or Position: OWNER
Credential: DMD
Phone: 558-299-3949