Healthcare Provider Details

I. General information

NPI: 1629119078
Provider Name (Legal Business Name): BRENT DRYDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 MAGNOLIA AVE
BUENA VISTA VA
24416-3121
US

IV. Provider business mailing address

2233 MAGNOLIA AVE
BUENA VISTA VA
24416-3121
US

V. Phone/Fax

Practice location:
  • Phone: 540-261-2284
  • Fax: 540-261-4355
Mailing address:
  • Phone: 540-261-2284
  • Fax: 540-261-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8788
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: