Provider Demographics
NPI:1215965918
Name:MARTINEAU, BRENT N
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:N
Last Name:MARTINEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15341 W WADDELL RD
Mailing Address - Street 2:B-107
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5169
Mailing Address - Country:US
Mailing Address - Phone:623-975-3933
Mailing Address - Fax:623-975-3493
Practice Address - Street 1:105 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1617
Practice Address - Country:US
Practice Address - Phone:623-932-3200
Practice Address - Fax:623-932-3222
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD61121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice