Provider Demographics
NPI:1548954381
Name:BROOKE HIKADE WYATT, DMD, LLC
Entity type:Organization
Organization Name:BROOKE HIKADE WYATT, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUILOBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-558-9828
Mailing Address - Street 1:14210 SE SUNNYSIDE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5242
Mailing Address - Country:US
Mailing Address - Phone:503-558-9828
Mailing Address - Fax:503-558-9829
Practice Address - Street 1:14210 SE SUNNYSIDE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5242
Practice Address - Country:US
Practice Address - Phone:503-558-9828
Practice Address - Fax:503-558-9829
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKE HIKADE WYATT, DMD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty