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General NPI Number Information
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NPI Number | 1225612534
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Entity Type | Organization
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Legal Business Name | BROOKFIELD ORAL SURGERY, LLC
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Dates
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Enumeration Date | 05/12/2021
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Last Update Date | 05/12/2021
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Provider Practice Location Address
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Address Line | 9240 BROADWAY AVE
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City | BROOKFIELD
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State | IL
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Zip | 60513-1252
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Country | US
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Telephone | 708-680-7017
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Fax | 708-419-3537
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Provider Business Mailing Address
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Address Line | 27 ELMWOOD AVE
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City | LA GRANGE PARK
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State | IL
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Zip | 60526-2032
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Country | US
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Telephone | 708-680-7017
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TYRAN E JOHNSON
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Credential | DDS
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Telephone | 708-680-7017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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