Provider Demographics
NPI:1629427596
Name:BROOKS, SHANDRA PATRICE (RDH)
Entity Type:Individual
Prefix:MS
First Name:SHANDRA
Middle Name:PATRICE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 AIR ASSAULT AND DESERT STORM
Mailing Address - Street 2:
Mailing Address - City:FT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:270-798-6362
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2441 21ST STREET
Practice Address - Street 2:US ARMY DENTAL ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8977
Practice Address - Fax:270-956-0266
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4921124Q00000X
TN0000004921124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental Hygienist