Provider Demographics
NPI:1831531706
Name:BROOMHEAD, MARK JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:BROOMHEAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2329
Mailing Address - Country:US
Mailing Address - Phone:773-817-5500
Mailing Address - Fax:
Practice Address - Street 1:615 E 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2329
Practice Address - Country:US
Practice Address - Phone:773-817-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190267401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice