Provider Demographics
NPI:1225612534
Name:BROOKFIELD ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:BROOKFIELD ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYRAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-680-7017
Mailing Address - Street 1:27 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-2032
Mailing Address - Country:US
Mailing Address - Phone:708-680-7017
Mailing Address - Fax:
Practice Address - Street 1:9240 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1252
Practice Address - Country:US
Practice Address - Phone:708-680-7017
Practice Address - Fax:708-419-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty