Healthcare Provider Details

I. General information

NPI: 1275515280
Provider Name (Legal Business Name): BRENT CALVIN MACKAY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5571 SCOTTWOOD RD
PARADISE CA
95969-5043
US

IV. Provider business mailing address

5571 SCOTTWOOD RD
PARADISE CA
95969-5043
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-8694
  • Fax: 530-877-8038
Mailing address:
  • Phone: 530-877-8694
  • Fax: 530-877-8038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: