Provider Demographics
NPI:1588749493
Name:KELLOGG, BRENT NELSON (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:NELSON
Last Name:KELLOGG
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 1:1809 100TH PL SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3829
Mailing Address - Country:US
Mailing Address - Phone:425-337-3922
Mailing Address - Fax:425-337-6453
Practice Address - Street 1:1809 100TH PL SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3829
Practice Address - Country:US
Practice Address - Phone:425-337-3922
Practice Address - Fax:425-337-6453
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000051781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice