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General NPI Number Information
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NPI Number | 1114535457
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Entity Type | Individual
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Provider Name | BRENT LEE CRENSHAW DMD
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Gender | Male
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 08/12/2024
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Provider Practice Location Address
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Address Line | 8859 LADUE RD
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City | SAINT LOUIS
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State | MO
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Zip | 63124-2045
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Country | US
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Telephone | 314-983-8011
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Fax |
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Provider Business Mailing Address
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Address Line | 33 WILLIAMSBURG LN
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City | GLEN CARBON
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State | IL
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Zip | 62034-1100
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Country | US
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Telephone | 618-334-6373
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2020021490
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.032764
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License Number State | IL
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