MEDICARE: BRENT EDGEWORTH BOYETT DMD, DO

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	1223G0001X	General Practice Dentistry	4622	AL
2	207Q00000X	Family Medicine Physician	DO654	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235211129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT EDGEWORTH BOYETT DMD, DO

Provider Business Mailing Address
First Line	:	2131 MILITARY ST S
Second Line	:
City	:	HAMILTON
State	:	AL
Zip	:	35570-6651
Country	:	US
Telephone Number	:	205-921-0893
Fax Number	:	205-921-6723

Provider Business Practice Location Address
First Line	:	2131 MILITARY ST S
Second Line	:
City	:	HAMILTON
State	:	AL
Zip	:	35570-6651
Country	:	US
Telephone Number	:	205-921-5556
Fax Number	:	205-921-5595

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

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	08/24/2011

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