Provider Demographics
NPI:1396933669
Name:MAHAN, BROOK RACHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:BROOK
Middle Name:RACHELLE
Last Name:MAHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 BLACKMON LN
Mailing Address - Street 2:#1
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7927
Mailing Address - Country:US
Mailing Address - Phone:409-898-8602
Mailing Address - Fax:409-898-8618
Practice Address - Street 1:3590 BLACKMON LN
Practice Address - Street 2:#1
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7927
Practice Address - Country:US
Practice Address - Phone:409-898-8602
Practice Address - Fax:409-898-8618
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist