Healthcare Provider Details

I. General information

NPI: 1780742023
Provider Name (Legal Business Name): BRENT R CARMONY M.S., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 COWHORN CREEK ROAD
TEXARKANA TX
75503
US

IV. Provider business mailing address

5305 COWHORN CREEK ROAD
TEXARKANA TX
75503
US

V. Phone/Fax

Practice location:
  • Phone: 903-791-8405
  • Fax: 903-793-1046
Mailing address:
  • Phone: 903-791-8405
  • Fax: 903-793-1046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19239
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: