Provider Demographics
NPI:1053093658
Name:EDGAR, BROOKE A
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:EDGAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RALEY BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-8352
Mailing Address - Country:US
Mailing Address - Phone:530-570-7471
Mailing Address - Fax:
Practice Address - Street 1:101 RALEY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-8352
Practice Address - Country:US
Practice Address - Phone:530-570-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26865124Q00000X
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist