Healthcare Provider Details

I. General information

NPI: 1568072668
Provider Name (Legal Business Name): BRIMFIELD FAMILY DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 E KNOXVILLE ST
BRIMFIELD IL
61517-8103
US

IV. Provider business mailing address

232 E KNOXVILLE ST
BRIMFIELD IL
61517-8103
US

V. Phone/Fax

Practice location:
  • Phone: 309-320-8750
  • Fax: 309-233-2023
Mailing address:
  • Phone: 309-396-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLINT MARTIN
Title or Position: PRESIDENT
Credential: DMD
Phone: 309-396-3123