Healthcare Provider Details

I. General information

NPI: 1164412441
Provider Name (Legal Business Name): BRENT SONDAY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 FALCON PARKWAY
SCHRIEVER, AFB CO
80912
US

IV. Provider business mailing address

220 FALCON PARKWAY
SCHRIEVER, AFB CO
80912
US

V. Phone/Fax

Practice location:
  • Phone: 719-567-5467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4620-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: