MEDICARE: DR. BROOKE NORDQUIST DDS

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	122300000X	Dentist	7394	NE

General Provider Information

NPI Number	:	1902326986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BROOKE NORDQUIST DDS

Provider Business Mailing Address
First Line	:	115 ROSEBUD LN
Second Line	:
City	:	COUNCIL BLUFFS
State	:	IA
Zip	:	51503-5304
Country	:	US
Telephone Number	:	712-269-7583
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 L ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68117-1329
Country	:	US
Telephone Number	:	402-731-5423
Fax Number	:

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

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	06/21/2017

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