Provider Demographics
NPI:1821252958
Name:BROOKS, DETRA KASHON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DETRA
Middle Name:KASHON
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 E WT HARRIS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-5138
Mailing Address - Country:US
Mailing Address - Phone:704-494-4050
Mailing Address - Fax:
Practice Address - Street 1:2225 E WT HARRIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5138
Practice Address - Country:US
Practice Address - Phone:704-494-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899006NMedicaid