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General NPI Number Information
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NPI Number | 1114472297
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Entity Type | Organization
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Legal Business Name | DRS.BROKAW AND GERMAN
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Dates
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Enumeration Date | 08/18/2016
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Last Update Date | 08/18/2016
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Provider Practice Location Address
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Address Line | 123 N HENNEPIN AVE
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City | DIXON
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State | IL
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Zip | 61021-2010
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Country | US
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Telephone | 815-284-6807
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Fax |
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Provider Business Mailing Address
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Address Line | 123 N HENNEPIN AVE
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City | DIXON
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State | IL
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Zip | 61021-2010
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Country | US
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Telephone | 815-284-6807
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. REBECCA BARTLETT
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Credential |
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Telephone | 815-284-6807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019019615
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019018857
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License Number State | IL
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