Provider Demographics
NPI:1851312839
Name:BROOKSIDE DENTAL
Entity Type:Organization
Organization Name:BROOKSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:HAMBLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-461-2600
Mailing Address - Street 1:351 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-461-2600
Mailing Address - Fax:208-461-3166
Practice Address - Street 1:351 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2856
Practice Address - Country:US
Practice Address - Phone:208-461-2600
Practice Address - Fax:208-461-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty