Provider Demographics
NPI:1619351251
Name:BROOKSTONE DENTAL, PLLC
Entity Type:Organization
Organization Name:BROOKSTONE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:423-247-8172
Mailing Address - Street 1:4260 FORT HENRY DR
Mailing Address - Street 2:STE 13
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2248
Mailing Address - Country:US
Mailing Address - Phone:423-239-6594
Mailing Address - Fax:
Practice Address - Street 1:4260 FORT HENRY DR
Practice Address - Street 2:STE 13
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2248
Practice Address - Country:US
Practice Address - Phone:423-239-6594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty