Provider Demographics
NPI:1548434095
Name:DR MITCHELL BROOKSTONE DDS PC
Entity type:Organization
Organization Name:DR MITCHELL BROOKSTONE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROOKSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-826-1666
Mailing Address - Street 1:1228 WANTAGH AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:516-826-1666
Mailing Address - Fax:516-783-7716
Practice Address - Street 1:1228 WANTAGH AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793
Practice Address - Country:US
Practice Address - Phone:516-826-1666
Practice Address - Fax:516-783-7716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty