Healthcare Provider Details

I. General information

NPI: 1093508756
Provider Name (Legal Business Name): BRYAR JEANNINE BROOKS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5183 HINKLEVILLE RD
PADUCAH KY
42001-9667
US

IV. Provider business mailing address

225 N 31ST ST
PADUCAH KY
42001-4317
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-9006
  • Fax:
Mailing address:
  • Phone: 715-326-1424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11375
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: