Provider Demographics
NPI:1285762971
Name:MCBROOM, CHARLES ANTHONY (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:MCBROOM
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 1:1029 HOWARD ST STE 203
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3877
Mailing Address - Country:US
Mailing Address - Phone:847-491-0660
Mailing Address - Fax:
Practice Address - Street 1:1029 HOWARD ST STE 203
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3877
Practice Address - Country:US
Practice Address - Phone:847-491-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026519122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist