Provider Demographics
NPI:1689217523
Name:ADVANCED DENTAL CENTER BROOKS
Entity type:Organization
Organization Name:ADVANCED DENTAL CENTER BROOKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TALIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-966-4367
Mailing Address - Street 1:8517 PRESTON HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5301
Mailing Address - Country:US
Mailing Address - Phone:502-966-4367
Mailing Address - Fax:
Practice Address - Street 1:1064 BROOKS HILL RD
Practice Address - Street 2:
Practice Address - City:BROOKS
Practice Address - State:KY
Practice Address - Zip Code:40109-5149
Practice Address - Country:US
Practice Address - Phone:502-955-1084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental