Provider Demographics
NPI:1134207459
Name:BROOKWOOD LLC
Entity type:Organization
Organization Name:BROOKWOOD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-349-1070
Mailing Address - Street 1:733 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3535
Mailing Address - Country:US
Mailing Address - Phone:636-349-1070
Mailing Address - Fax:
Practice Address - Street 1:733 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3535
Practice Address - Country:US
Practice Address - Phone:636-349-1070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty