Provider Demographics
NPI:1770704686
Name:BROCKMAN, AMY ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:ELIZABETH
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:620 MULBERRY ST.
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077
Mailing Address - Country:US
Mailing Address - Phone:317-536-8445
Mailing Address - Fax:
Practice Address - Street 1:170 S. CREASY LANE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905
Practice Address - Country:US
Practice Address - Phone:765-448-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010934A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice