=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346839263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE MIDDENDORF CDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2021
-----------------------------------------------------
Last Update Date | 01/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 OGDEN AVE
-----------------------------------------------------
City | CLARENDON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60514-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-320-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 OGDEN AVE
-----------------------------------------------------
City | CLARENDON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60514-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-320-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 1179030
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------