Provider Demographics
NPI:1518936020
Name:BROOKS, DALTON PETER JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DALTON
Middle Name:PETER
Last Name:BROOKS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:DALTON
Other - Middle Name:PETER
Other - Last Name:BROOKS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DMD, PLLC
Mailing Address - Street 1:727 WESLEY PINES RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2105
Mailing Address - Country:US
Mailing Address - Phone:910-618-0384
Mailing Address - Fax:
Practice Address - Street 1:727 WESLEY PINES RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2105
Practice Address - Country:US
Practice Address - Phone:910-618-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990092Medicaid
NC90092OtherBCBS OF NC
NC8990092Medicaid