Provider Demographics
NPI:1487148979
Name:CLINE, BRENT WILLIAM
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:WILLIAM
Last Name:CLINE
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 1:467 PHEASANT RIDGE DR APT B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1755
Mailing Address - Country:US
Mailing Address - Phone:208-201-5780
Mailing Address - Fax:
Practice Address - Street 1:675 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4511
Practice Address - Country:US
Practice Address - Phone:208-478-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist