Provider Demographics
NPI:1104931633
Name:PACKER, BRENT TAYLOR (DMD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:TAYLOR
Last Name:PACKER
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 1:1400 N GILBERT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2328
Mailing Address - Country:US
Mailing Address - Phone:480-892-5089
Mailing Address - Fax:480-892-4236
Practice Address - Street 1:1400 N GILBERT RD
Practice Address - Street 2:SUITE A
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2328
Practice Address - Country:US
Practice Address - Phone:480-892-5089
Practice Address - Fax:480-892-4236
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice