Provider Demographics
NPI:1417244401
Name:BROOKS, CHARLES BRANDTEN (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRANDTEN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WEST 13TH
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601
Mailing Address - Country:US
Mailing Address - Phone:785-621-5142
Mailing Address - Fax:785-628-8718
Practice Address - Street 1:105 WEST 13TH
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601
Practice Address - Country:US
Practice Address - Phone:785-621-5142
Practice Address - Fax:785-628-8719
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-29
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist