Provider Demographics
NPI:1538391040
Name:DAVIS, BRENDEN J (DMD, MPH)
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 N DOLARWAY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8392
Mailing Address - Country:US
Mailing Address - Phone:509-925-7600
Mailing Address - Fax:509-925-9646
Practice Address - Street 1:910 S COLUMBIA CENTER BLVD STE D
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-9560
Practice Address - Country:US
Practice Address - Phone:509-607-1872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601039561223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0255549OtherLABOR & INDUSTRIES
WA5060215Medicaid
WA5060215Medicaid