Provider Demographics
NPI:1871602805
Name:KOUDELKA, BRENT MILLER (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MILLER
Last Name:KOUDELKA
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 1:6900 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20307-5400
Mailing Address - Country:US
Mailing Address - Phone:202-782-0988
Mailing Address - Fax:202-782-9195
Practice Address - Street 1:6900 GEORGIA AVE NW
Practice Address - Street 2:BUILDING 2 ROOM 1D
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-5400
Practice Address - Country:US
Practice Address - Phone:202-782-6815
Practice Address - Fax:202-782-6987
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30013909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist