Healthcare Provider Details

I. General information

NPI: 1700310489
Provider Name (Legal Business Name): JORDAN BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 S LUBEC RD
LUBEC ME
04652-3620
US

IV. Provider business mailing address

192 MAIN ST APT B
MACHIAS ME
04654-3600
US

V. Phone/Fax

Practice location:
  • Phone: 207-733-5541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH4096
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: