Provider Demographics
NPI:1619606522
Name:BRAKER, SETH (DMD)
Entity type:Individual
Prefix:DR
First Name:SETH
Middle Name:
Last Name:BRAKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S 4TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-3401
Mailing Address - Country:US
Mailing Address - Phone:309-370-5853
Mailing Address - Fax:
Practice Address - Street 1:1600 S 4TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-3401
Practice Address - Country:US
Practice Address - Phone:309-263-2781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice