Provider Demographics
NPI:1386874113
Name:BRIMHALL, BROC WAYNE (DMD)
Entity type:Individual
Prefix:
First Name:BROC
Middle Name:WAYNE
Last Name:BRIMHALL
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 1:9170 JEWEL LAKE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-5390
Mailing Address - Country:US
Mailing Address - Phone:907-248-7275
Mailing Address - Fax:907-248-7221
Practice Address - Street 1:9170 JEWEL LAKE RD STE 201
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99502-5390
Practice Address - Country:US
Practice Address - Phone:907-248-7275
Practice Address - Fax:907-248-7221
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13081223G0001X
AZ77961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0040Medicaid