Provider Demographics
NPI:1508081332
Name:BROKENSHIRE, JOHN ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:BROKENSHIRE
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 1:769 BLOOM RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1364
Mailing Address - Country:US
Mailing Address - Phone:570-275-1451
Mailing Address - Fax:570-271-1533
Practice Address - Street 1:769 BLOOM RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1364
Practice Address - Country:US
Practice Address - Phone:570-275-1451
Practice Address - Fax:570-271-1533
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024189L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice