Provider Demographics
NPI:1407921844
Name:BRACKETT, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WALKER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-1351
Mailing Address - Country:US
Mailing Address - Phone:630-323-2047
Mailing Address - Fax:630-323-6155
Practice Address - Street 1:4 WALKER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-1351
Practice Address - Country:US
Practice Address - Phone:630-323-2047
Practice Address - Fax:630-323-6155
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice