Provider Demographics
NPI:1942748140
Name:BRENNEN, ALISHA DIANE (DDS)
Entity type:Individual
Prefix:DR
First Name:ALISHA
Middle Name:DIANE
Last Name:BRENNEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 TOLEDO TER APT 320
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-4207
Mailing Address - Country:US
Mailing Address - Phone:952-262-9328
Mailing Address - Fax:
Practice Address - Street 1:10201 MARTIN LUTHER KING JR HWY UNIT 240A
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4003
Practice Address - Country:US
Practice Address - Phone:240-764-5753
Practice Address - Fax:240-764-5799
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16215122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD800126350Medicaid