Healthcare Provider Details

I. General information

NPI: 1598161127
Provider Name (Legal Business Name): CAROL BRENNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL LOGSDON BRENNER RDH

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 ELLIS WAY
LOUISVILLE KY
40220-1944
US

IV. Provider business mailing address

3312 ELLIS WAY
LOUISVILLE KY
40220-1944
US

V. Phone/Fax

Practice location:
  • Phone: 502-458-9420
  • Fax:
Mailing address:
  • Phone: 502-458-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0900
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: