Provider Demographics
NPI:1598834251
Name:BROOKSIDE DENTAL CARE, LTD.
Entity type:Organization
Organization Name:BROOKSIDE DENTAL CARE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-469-8837
Mailing Address - Street 1:10175 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1274
Mailing Address - Country:US
Mailing Address - Phone:815-469-8837
Mailing Address - Fax:815-469-8837
Practice Address - Street 1:10175 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1274
Practice Address - Country:US
Practice Address - Phone:815-469-8837
Practice Address - Fax:815-469-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty