Provider Demographics
NPI:1336941491
Name:BRKN DENTAL PLLC
Entity type:Organization
Organization Name:BRKN DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALAJ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:408-202-1013
Mailing Address - Street 1:2958 MISSION LAKES DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2958 MISSION LAKES DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5909
Practice Address - Country:US
Practice Address - Phone:408-202-1014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-27
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental