Provider Demographics
NPI:1144471400
Name:PENNINGTON, BRENT W (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:PENNINGTON
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 1:37 GATEWAY BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-7395
Mailing Address - Country:US
Mailing Address - Phone:706-935-2900
Mailing Address - Fax:
Practice Address - Street 1:37 GATEWAY BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-7395
Practice Address - Country:US
Practice Address - Phone:706-935-2900
Practice Address - Fax:706-935-2904
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA484260991CMedicaid