Healthcare Provider Details

I. General information

NPI: 1205459294
Provider Name (Legal Business Name): BROOKE BORUSIEWICZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/25/2020
Certification Date: 05/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 AIRFRAME DR
NORTH CHARLESTON SC
29418
US

IV. Provider business mailing address

219 FORT ST
SUMMERVILLE SC
29485-8387
US

V. Phone/Fax

Practice location:
  • Phone: 843-925-9296
  • Fax:
Mailing address:
  • Phone: 843-302-2817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10412
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: