Provider Demographics
NPI:1548480791
Name:DESIRE BROOKS, RAFAELE CAMILLE (DDS)
Entity type:Individual
Prefix:
First Name:RAFAELE
Middle Name:CAMILLE
Last Name:DESIRE BROOKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 LINCOLN BLVD
Mailing Address - Street 2:#743
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:310-822-6518
Mailing Address - Fax:310-822-6518
Practice Address - Street 1:11633 HAWTHORNE BLVD
Practice Address - Street 2:#500
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-644-4412
Practice Address - Fax:310-644-7355
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist