Provider Demographics
NPI:1154876019
Name:CCD BROOKWOOD, LLC
Entity type:Organization
Organization Name:CCD BROOKWOOD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-2424
Mailing Address - Street 1:2 COWPATH RD.
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446
Mailing Address - Country:US
Mailing Address - Phone:215-368-2424
Mailing Address - Fax:215-361-7292
Practice Address - Street 1:2 COWPATH RD.
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446
Practice Address - Country:US
Practice Address - Phone:215-368-2424
Practice Address - Fax:215-361-7292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty