Healthcare Provider Details

I. General information

NPI: 1487860151
Provider Name (Legal Business Name): BILLY BROOKS BROWN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 S BROADWAY AVE
BARTOW FL
33830-4615
US

IV. Provider business mailing address

695 S BROADWAY AVE
BARTOW FL
33830-4615
US

V. Phone/Fax

Practice location:
  • Phone: 863-533-0955
  • Fax: 863-533-6468
Mailing address:
  • Phone: 863-533-0955
  • Fax: 863-533-6468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7209
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7209
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: