Healthcare Provider Details

I. General information

NPI: 1194551804
Provider Name (Legal Business Name): BROOKSIDE DENTAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E 840 S
OREM UT
84058-5018
US

IV. Provider business mailing address

211 E 840 S
OREM UT
84058-5018
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-9511
  • Fax:
Mailing address:
  • Phone: 801-375-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID BROOKS
Title or Position: MEMBER
Credential: DDS
Phone: 801-550-5013