Healthcare Provider Details

I. General information

NPI: 1801881149
Provider Name (Legal Business Name): ROB M BRENT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 05/30/2006

III. Provider practice location address

1902 N TRACY BLVD
TRACY CA
95376-2423
US

IV. Provider business mailing address

2619 VISTA DIABLO CT
PLEASANTON CA
94566-7033
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-1242
  • Fax:
Mailing address:
  • Phone: 925-462-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number31444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: