Provider Demographics
NPI:1972993657
Name:DR. BROOKS DENTAL CORP
Entity Type:Organization
Organization Name:DR. BROOKS DENTAL CORP
Other - Org Name:JENNIFER BROOKS DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BASS
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:415-457-2244
Mailing Address - Street 1:508 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2436
Mailing Address - Country:US
Mailing Address - Phone:415-457-2244
Mailing Address - Fax:
Practice Address - Street 1:508 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2436
Practice Address - Country:US
Practice Address - Phone:415-457-2244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64234261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental