Provider Demographics
NPI:1043628670
Name:MEDEMA, BRENT A (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:A
Last Name:MEDEMA
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 1:7090 HICKORY POINT DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4039
Mailing Address - Country:US
Mailing Address - Phone:269-760-5505
Mailing Address - Fax:
Practice Address - Street 1:9021 N RODGERS CT SE
Practice Address - Street 2:SUITE E
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-7649
Practice Address - Country:US
Practice Address - Phone:616-891-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010213101223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics