Provider Demographics
NPI:1548489354
Name:VERHEECKE, BRENT M (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:M
Last Name:VERHEECKE
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 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1485
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1485
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2012-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190270071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice