MEDICARE: BROOKFIELD ORAL SURGERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1225612534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKFIELD ORAL SURGERY, LLC

Provider Business Mailing Address
First Line	:	27 ELMWOOD AVE
Second Line	:
City	:	LA GRANGE PARK
State	:	IL
Zip	:	60526-2032
Country	:	US
Telephone Number	:	708-680-7017
Fax Number	:

Provider Business Practice Location Address
First Line	:	9240 BROADWAY AVE
Second Line	:
City	:	BROOKFIELD
State	:	IL
Zip	:	60513-1252
Country	:	US
Telephone Number	:	708-680-7017
Fax Number	:	708-419-3537

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TYRAN E JOHNSON
Credential	:	DDS
Telephone Number	:	708-680-7017

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	05/12/2021

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Directions to “BROOKFIELD ORAL SURGERY, LLC ” Practice Location

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