Provider Demographics
NPI:1346393303
Name:BROOKS, SUSAN ROGERS (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ROGERS
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 CONWAY BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-7050
Mailing Address - Country:US
Mailing Address - Phone:941-629-4311
Mailing Address - Fax:
Practice Address - Street 1:3440 CONWAY BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7050
Practice Address - Country:US
Practice Address - Phone:941-629-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist