Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 031116 | NY |
NPI | 1134142169 |
---|---|
Provider Name | Dr. Jeffrey R Brook |
First Address | Massapequa, NY 11758-2345 |
Second Address | Massapequa, NY 11758-2345 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 08/07/2007 |