Provider Demographics
NPI:1821588260
Name:DEBROECK, SHARON LISA
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:LISA
Last Name:DEBROECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 2ND PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-4106
Mailing Address - Country:US
Mailing Address - Phone:718-797-5437
Mailing Address - Fax:
Practice Address - Street 1:62 2ND PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-4106
Practice Address - Country:US
Practice Address - Phone:718-797-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD174711223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics