Provider Demographics
NPI:1912029703
Name:BROOKS, TIM JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIM
Middle Name:JACK
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:STE 134
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1787
Mailing Address - Country:US
Mailing Address - Phone:405-752-0600
Mailing Address - Fax:
Practice Address - Street 1:12448 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8601
Practice Address - Country:US
Practice Address - Phone:405-752-0600
Practice Address - Fax:405-751-6362
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice