Provider Demographics
NPI:1811054323
Name:MILLS, BROOK (DMD)
Entity type:Individual
Prefix:DR
First Name:BROOK
Middle Name:
Last Name:MILLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 KY 459
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-7473
Mailing Address - Country:US
Mailing Address - Phone:606-545-7246
Mailing Address - Fax:
Practice Address - Street 1:646 MANCHESTER ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1720
Practice Address - Country:US
Practice Address - Phone:606-545-6055
Practice Address - Fax:606-545-6045
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY080881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002706Medicaid