Provider Demographics
NPI:1194551804
Name:BROOKSIDE DENTAL MANAGEMENT
Entity type:Organization
Organization Name:BROOKSIDE DENTAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-550-5013
Mailing Address - Street 1:211 E 840 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5018
Mailing Address - Country:US
Mailing Address - Phone:801-375-9511
Mailing Address - Fax:
Practice Address - Street 1:211 E 840 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5018
Practice Address - Country:US
Practice Address - Phone:801-375-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental