Provider Demographics
NPI:1275200677
Name:PHELON, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PHELON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NE LOOP 410 STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5834
Mailing Address - Country:US
Mailing Address - Phone:210-951-3280
Mailing Address - Fax:210-858-9220
Practice Address - Street 1:45 NE LOOP 410 STE 400
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5834
Practice Address - Country:US
Practice Address - Phone:210-951-3280
Practice Address - Fax:210-858-9220
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant