Healthcare Provider Details

I. General information

NPI: 1104552785
Provider Name (Legal Business Name): BARBARA BRENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

115 ARROW DR
CLINTON MS
39056-3112
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6338
  • Fax:
Mailing address:
  • Phone: 601-926-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1913-81DH
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: