Provider Demographics
NPI:1093508756
Name:BROOKS, BRYAR JEANNINE (DMD)
Entity type:Individual
Prefix:
First Name:BRYAR
Middle Name:JEANNINE
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4317
Mailing Address - Country:US
Mailing Address - Phone:715-326-1424
Mailing Address - Fax:
Practice Address - Street 1:5183 HINKLEVILLE RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9667
Practice Address - Country:US
Practice Address - Phone:270-415-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY11375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program