Provider Demographics
NPI:1205459294
Name:BORUSIEWICZ, BROOKE (RDH)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BORUSIEWICZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8387
Mailing Address - Country:US
Mailing Address - Phone:843-302-2817
Mailing Address - Fax:
Practice Address - Street 1:3455 AIRFRAME DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418
Practice Address - Country:US
Practice Address - Phone:843-925-9296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10412124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist