Healthcare Provider Details

I. General information

NPI: 1528286903
Provider Name (Legal Business Name): BRENDA M. O'BRIEN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 KEMP RD
BEAVERCREEK OH
45431-4200
US

IV. Provider business mailing address

10210 TILLMAN RD
CENTERVILLE FINANCE OH
45458-9185
US

V. Phone/Fax

Practice location:
  • Phone: 937-426-6860
  • Fax: 937-426-9703
Mailing address:
  • Phone: 937-885-9759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30020536
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: