Provider Demographics
NPI:1427273390
Name:MUTTON, BRENT EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:EDWARD
Last Name:MUTTON
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 1:7202 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-3459
Mailing Address - Fax:260-436-4757
Practice Address - Street 1:7202 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-432-3459
Practice Address - Fax:260-436-4757
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist