Provider Demographics
NPI:1174583306
Name:BROCKMAN, DOUGLAS JOHN (DDS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOHN
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5157
Mailing Address - Country:US
Mailing Address - Phone:513-423-9239
Mailing Address - Fax:
Practice Address - Street 1:210 S BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5157
Practice Address - Country:US
Practice Address - Phone:513-423-9239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH184881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0701379Medicaid
OH0743637Medicaid