Healthcare Provider Details

I. General information

NPI: 1083691273
Provider Name (Legal Business Name): MICHAEL D BROOKS D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19365 7TH AVE NE STE 114
POULSBO WA
98370-7441
US

IV. Provider business mailing address

19365 7TH AVE NE STE 114
POULSBO WA
98370-7441
US

V. Phone/Fax

Practice location:
  • Phone: 360-779-7414
  • Fax: 360-779-7732
Mailing address:
  • Phone: 360-779-7414
  • Fax: 360-779-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE00011225
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: