Provider Demographics
NPI:1326192030
Name:BROOKS, JENNIFER BASS (DMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BASS
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:508 RED HILL AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2473
Mailing Address - Country:US
Mailing Address - Phone:415-457-2244
Mailing Address - Fax:
Practice Address - Street 1:508 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2436
Practice Address - Country:US
Practice Address - Phone:415-457-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0129751223G0001X
CA642341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA64234OtherDENTAL LICENSE