Provider Demographics
NPI:1649742370
Name:BROOKFIELD DENTAL CENTER LLC
Entity Type:Organization
Organization Name:BROOKFIELD DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-873-0510
Mailing Address - Street 1:920 INDIAN SPRING DR
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2242
Mailing Address - Country:US
Mailing Address - Phone:262-646-2771
Mailing Address - Fax:262-646-2340
Practice Address - Street 1:17585 W NORTH AVE STE 210
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4365
Practice Address - Country:US
Practice Address - Phone:262-784-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental