Provider Demographics
NPI:1508035445
Name:BROOKFIELD FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BROOKFIELD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:THADDEOUS
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-821-1000
Mailing Address - Street 1:17185 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4428
Mailing Address - Country:US
Mailing Address - Phone:262-821-1000
Mailing Address - Fax:
Practice Address - Street 1:17185 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4428
Practice Address - Country:US
Practice Address - Phone:262-821-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1386867679OtherNPI