Provider Demographics
NPI:1679779532
Name:GOLDEN, BRENT ALLEN (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALLEN
Last Name:GOLDEN
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:207 W GORE ST STE 302
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1014
Mailing Address - Country:US
Mailing Address - Phone:407-839-8407
Mailing Address - Fax:407-839-8446
Practice Address - Street 1:207 W GORE ST STE 302
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1014
Practice Address - Country:US
Practice Address - Phone:407-839-8407
Practice Address - Fax:407-839-8446
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123445204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014953200Medicaid
FLIE133ZMedicare PIN