Provider Demographics
NPI:1992886618
Name:BRENT, DALE J (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:J
Last Name:BRENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1812
Mailing Address - Country:US
Mailing Address - Phone:818-784-1195
Mailing Address - Fax:818-784-6473
Practice Address - Street 1:4955 VAN NUYS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1812
Practice Address - Country:US
Practice Address - Phone:818-784-1195
Practice Address - Fax:818-784-6473
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102370Medicaid
CAGR0102370Medicaid
B50504Medicare UPIN