Provider Demographics
NPI:1255622692
Name:KIDD, BRENT DOUGLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DOUGLAS
Last Name:KIDD
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 1:1275 HALLWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351
Mailing Address - Country:US
Mailing Address - Phone:606-784-8000
Mailing Address - Fax:606-784-8004
Practice Address - Street 1:1275 HALLWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351
Practice Address - Country:US
Practice Address - Phone:606-784-8000
Practice Address - Fax:606-784-8004
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9075122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist