Provider Demographics
NPI:1699982355
Name:BROOKS, TIMOTHY MICHAEL (DENTIST)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9801 DUPONT AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-881-8983
Mailing Address - Fax:
Practice Address - Street 1:9801 DUPONT AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3100
Practice Address - Country:US
Practice Address - Phone:952-881-8983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice