Provider Demographics
NPI:1366897977
Name:BROOKS DENTAL ASSOCIATES, INC
Entity type:Organization
Organization Name:BROOKS DENTAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C. PASCHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:229-723-4111
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-0707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:229-723-6083
Practice Address - Street 1:13762 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-1875
Practice Address - Country:US
Practice Address - Phone:229-723-4111
Practice Address - Fax:229-723-6083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0141231223G0001X
GADN0072861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty