1629427596 NPI number — MS. SHANDRA PATRICE BROOKS RDH

Table of content: MS. SHANDRA PATRICE BROOKS RDH (NPI 1629427596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629427596 NPI number — MS. SHANDRA PATRICE BROOKS RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
SHANDRA
Provider Middle Name:
PATRICE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629427596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5580 AIR ASSAULT AND DESERT STORM
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT CAMPBELL
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-798-6362
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 2441 21ST STREET
Provider Second Line Business Practice Location Address:
US ARMY DENTAL ACTIVITY
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-798-8977
Provider Business Practice Location Address Fax Number:
270-956-0266
Provider Enumeration Date:
06/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  4921 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 124Q00000X , with the licence number: 0000004921 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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