Provider Demographics
NPI:1205940681
Name:BRUBAKER, JENNIFER K (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 BELT LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4380
Mailing Address - Country:US
Mailing Address - Phone:618-344-4527
Mailing Address - Fax:618-344-7380
Practice Address - Street 1:1099 BELT LINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4380
Practice Address - Country:US
Practice Address - Phone:618-344-4527
Practice Address - Fax:618-344-7380
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190270831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice