Provider Demographics
NPI:1003843798
Name:BREWER, GARTH I (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARTH
Middle Name:I
Last Name:BREWER
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 1:417 W MADISON ST
Mailing Address - Street 2:SUITE 101B
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2836
Mailing Address - Country:US
Mailing Address - Phone:815-433-1258
Mailing Address - Fax:815-433-9025
Practice Address - Street 1:417 W MADISON ST
Practice Address - Street 2:SUITE 101B
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2836
Practice Address - Country:US
Practice Address - Phone:815-433-1258
Practice Address - Fax:815-433-9025
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0198901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice