Provider Demographics
NPI:1275625519
Name:BROOKS COSMETIC & FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BROOKS COSMETIC & FAMILY DENTISTRY
Other - Org Name:BROOKS & MADDOX FAMILY DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-583-0330
Mailing Address - Street 1:70 WESTRIDGE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3048
Mailing Address - Country:US
Mailing Address - Phone:678-583-0330
Mailing Address - Fax:678-583-0660
Practice Address - Street 1:70 WESTRIDGE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3048
Practice Address - Country:US
Practice Address - Phone:678-583-0330
Practice Address - Fax:678-583-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty