MEDICARE: DR. JENNIFER K BRUBAKER DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019027083	IL

General Provider Information

NPI Number	:	1205940681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER K BRUBAKER DMD

Provider Business Mailing Address
First Line	:	1099 BELT LINE RD
Second Line	:	SUITE A
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4380
Country	:	US
Telephone Number	:	618-344-4527
Fax Number	:	618-344-7380

Provider Business Practice Location Address
First Line	:	1099 BELT LINE RD
Second Line	:	SUITE A
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4380
Country	:	US
Telephone Number	:	618-344-4527
Fax Number	:	618-344-7380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	04/18/2011

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