Provider Demographics
NPI:1508177825
Name:BROOKS, CHARLES PASCHAL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PASCHAL
Last Name:BROOKS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:CHASE
Other - Middle Name:PASCHAL
Other - Last Name:BROOKS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-0707
Mailing Address - Country:US
Mailing Address - Phone:229-723-4111
Mailing Address - Fax:229-723-6083
Practice Address - Street 1:13762 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-1875
Practice Address - Country:US
Practice Address - Phone:229-723-4111
Practice Address - Fax:229-723-6083
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice