Provider Demographics
NPI:1134672470
Name:BROOKS, BETHANY (DMD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUREAU OF MED AND SURGERY CREDENTIALS AND
Mailing Address - Street 2:554 KEILY STREET
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-0001
Mailing Address - Country:US
Mailing Address - Phone:757-953-1897
Mailing Address - Fax:
Practice Address - Street 1:BUREAU OF MED AND SURGERY CREDENTIALS AND
Practice Address - Street 2:554 KEILY STREET
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-0001
Practice Address - Country:US
Practice Address - Phone:757-953-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist