Provider Demographics
NPI:1497827869
Name:BROOK WEST FAMILY DENTISTRY PA
Entity Type:Organization
Organization Name:BROOK WEST FAMILY DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-561-2273
Mailing Address - Street 1:7950 MAIN ST
Mailing Address - Street 2:#205
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-561-2273
Mailing Address - Fax:763-561-5761
Practice Address - Street 1:7950 MAIN ST
Practice Address - Street 2:#205
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-561-2273
Practice Address - Fax:763-561-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty