Provider Demographics
NPI:1346839263
Name:MIDDENDORF, BROOKE (CDA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-2814
Mailing Address - Country:US
Mailing Address - Phone:630-320-8888
Mailing Address - Fax:
Practice Address - Street 1:433 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-2814
Practice Address - Country:US
Practice Address - Phone:630-320-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1179030126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant