MEDICARE: BROOKVILLE DENTAL PC

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	DS024744L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891719480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKVILLE DENTAL PC

Provider Business Mailing Address
First Line	:	123 MAIN ST
Second Line	:
City	:	BROOKVILLE
State	:	PA
Zip	:	15825-1212
Country	:	US
Telephone Number	:	814-849-2652
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 MAIN ST
Second Line	:
City	:	BROOKVILLE
State	:	PA
Zip	:	15825-1212
Country	:	US
Telephone Number	:	814-849-2652
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WILLIAM J WEAVER
Credential	:	D.M.D.
Telephone Number	:	814-849-2652

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	08/22/2020

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Directions to “BROOKVILLE DENTAL PC ” Practice Location

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