Provider Demographics
NPI:1902970171
Name:MCDONALD, BRENT C (DMD)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:C
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 KNOX ST
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-1304
Mailing Address - Country:US
Mailing Address - Phone:606-546-6711
Mailing Address - Fax:606-546-2574
Practice Address - Street 1:608 KNOX ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1304
Practice Address - Country:US
Practice Address - Phone:606-546-6711
Practice Address - Fax:606-546-2574
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY73841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60073848Medicaid