Healthcare Provider Details

I. General information

NPI: 1942297999
Provider Name (Legal Business Name): JOHN W BROOKS JR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 S GEDDES ST
SYRACUSE NY
13204-2809
US

IV. Provider business mailing address

201 W 8TH ST SUITE 810
PUEBLO CO
81003-3038
US

V. Phone/Fax

Practice location:
  • Phone: 315-471-0550
  • Fax: 315-471-0770
Mailing address:
  • Phone: 719-562-4447
  • Fax: 719-583-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4394
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number042029
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: