Provider Demographics
NPI:1043575285
Name:BROOKS, THOMAS LEE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEE
Last Name:BROOKS
Suffix:JR
Gender:M
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:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:NAHUNTA
Mailing Address - State:GA
Mailing Address - Zip Code:31553-0586
Mailing Address - Country:US
Mailing Address - Phone:912-462-5610
Mailing Address - Fax:912-462-6405
Practice Address - Street 1:9863 MAIN ST N
Practice Address - Street 2:
Practice Address - City:NAHUNTA
Practice Address - State:GA
Practice Address - Zip Code:31553-6123
Practice Address - Country:US
Practice Address - Phone:912-462-5610
Practice Address - Fax:912-462-6405
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN105341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129162BMedicaid