MEDICARE: WENDY BROKKEN

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	124Q00000X	Dental Hygienist	905286	CO

General Provider Information

NPI Number	:	1396959649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY BROKKEN

Provider Business Mailing Address
First Line	:	3996 RED CEDAR DR
Second Line	:	STE A-3
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80126-8065
Country	:	US
Telephone Number	:	303-470-9696
Fax Number	:

Provider Business Practice Location Address
First Line	:	3996 RED CEDAR DR
Second Line	:	STE A-3
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80126-8065
Country	:	US
Telephone Number	:	303-470-9696
Fax Number	:

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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