Healthcare Provider Details

I. General information

NPI: 1124644950
Provider Name (Legal Business Name): ROBERT THIBEAULT BROOKINGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 GROVE STREET
BANGOR ME
04401-5309
US

IV. Provider business mailing address

39 GROVE ST
BANGOR ME
04401-5309
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-6239
  • Fax: 207-947-4703
Mailing address:
  • Phone: 207-944-9980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN4807
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: