Healthcare Provider Details

I. General information

NPI: 1295717775
Provider Name (Legal Business Name): BRENT JOHN WALDMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13145 KINGS LAKE DR
GIBSONTON FL
33534-3962
US

IV. Provider business mailing address

15231 MERLINGLEN PL
LITHIA FL
33547-3900
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-9738
  • Fax:
Mailing address:
  • Phone: 843-789-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401410971
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN28891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: