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General NPI Number Information
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NPI Number | 1295717775
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Entity Type | Individual
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Provider Name | BRENT JOHN WALDMAN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 11/18/2005
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 13145 KINGS LAKE DR
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City | GIBSONTON
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State | FL
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Zip | 33534-3962
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Country | US
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Telephone | 843-789-9738
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Fax |
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Provider Business Mailing Address
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Address Line | 15231 MERLINGLEN PL
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City | LITHIA
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State | FL
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Zip | 33547-3900
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Country | US
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Telephone | 843-789-9738
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401410971
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN28891
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License Number State | FL
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