Healthcare Provider Details

I. General information

NPI: 1952655375
Provider Name (Legal Business Name): BROOKE TERRY AHLSTROM DMD, MS, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL AMERICANO BASE NAVAL DE ROTA
ROTA CADIZ
11530
ES

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0001
US

V. Phone/Fax

Practice location:
  • Phone: 315-727-3608
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD008480
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD008480
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: