Provider Demographics
NPI:1730407115
Name:BROCKENBERRY, CHRISTIAN TIFFANY (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:TIFFANY
Last Name:BROCKENBERRY
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 1:400 COLUMBUS AVE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3040
Mailing Address - Fax:203-503-3187
Practice Address - Street 1:428 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1233
Practice Address - Country:US
Practice Address - Phone:203-503-3040
Practice Address - Fax:203-503-3187
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036565Medicaid
CT0051536OtherCSR
CTFG2899055OtherDEA