Provider Demographics
NPI:1689754327
Name:NOONAN, BROCKMAN AND POLLOCK, D.D.S., INC.
Entity Type:Organization
Organization Name:NOONAN, BROCKMAN AND POLLOCK, D.D.S., INC.
Other - Org Name:NOONAN AND BROCKMAN, D.D.S., INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-423-9239
Mailing Address - Street 1:210 S BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5157
Mailing Address - Country:US
Mailing Address - Phone:513-423-9239
Mailing Address - Fax:513-423-4188
Practice Address - Street 1:210 S BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5157
Practice Address - Country:US
Practice Address - Phone:513-423-9239
Practice Address - Fax:513-423-4188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0743637Medicaid
OH2705826Medicaid
OH0184072Medicaid
OH0701379Medicaid