Provider Demographics
NPI:1902890676
Name:GILLILAND, BRENT LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LESLIE
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 THOREAU TRL
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-1158
Mailing Address - Country:US
Mailing Address - Phone:210-845-1387
Mailing Address - Fax:
Practice Address - Street 1:12TH AEROMEDICAL-DENTAL SQUADRON
Practice Address - Street 2:221 3RD STREET WEST
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150-4801
Practice Address - Country:US
Practice Address - Phone:210-652-1846
Practice Address - Fax:210-652-1368
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice