MEDICARE: DR. BRIAN PENTON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D11755	MN
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	34385	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D11755	OTHER	MN	DENTIST

General Provider Information

NPI Number	:	1053303644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN PENTON DDS

Provider Business Mailing Address
First Line	:	1615 TRUEMPER ST BLDG 6418
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5511
Country	:	US
Telephone Number	:	210-292-0694
Fax Number	:

Provider Business Practice Location Address
First Line	:	1615 TRUEMPER ST BLDG 6418
Second Line	:
City	:	LACKLAND AFB
State	:	TX
Zip	:	78236-5511
Country	:	US
Telephone Number	:	210-292-0694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	12/30/2021

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Directions to “ DR. BRIAN PENTON DDS” Practice Location

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