Provider Demographics
NPI:1275782252
Name:DR. DALTON PETER BROOKS, JR., DMD, PLLC
Entity Type:Organization
Organization Name:DR. DALTON PETER BROOKS, JR., DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:910-674-3672
Mailing Address - Street 1:727 WESLEY PINES RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2105
Mailing Address - Country:US
Mailing Address - Phone:910-674-3672
Mailing Address - Fax:910-674-3673
Practice Address - Street 1:727 WESLEY PINES RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2105
Practice Address - Country:US
Practice Address - Phone:910-674-3672
Practice Address - Fax:910-674-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990092Medicaid
NC90092OtherBCBS
NC8990092Medicaid