MEDICARE: DR. THOMAS GLENN BROOKS DMD

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	1223G0001X	General Practice Dentistry	D6262	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D6262	OTHER	OR	DENTAL LICENSE

General Provider Information

NPI Number	:	1306974035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS GLENN BROOKS DMD

Provider Business Mailing Address
First Line	:	PO BOX 198
Second Line	:
City	:	GOLD HILL
State	:	OR
Zip	:	97525-0198
Country	:	US
Telephone Number	:	541-855-7920
Fax Number	:	541-855-2511

Provider Business Practice Location Address
First Line	:	492 SECOND AVE
Second Line	:
City	:	GOLD HILL
State	:	OR
Zip	:	97525-0198
Country	:	US
Telephone Number	:	541-855-7920
Fax Number	:	541-855-2511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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