Provider Demographics
NPI:1043691330
Name:JOHNSON, BROOKE BURNETTE (DMD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:BURNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:CHERYL
Other - Last Name:BURNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3769 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3327
Mailing Address - Country:US
Mailing Address - Phone:252-443-0048
Mailing Address - Fax:
Practice Address - Street 1:3769 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3327
Practice Address - Country:US
Practice Address - Phone:252-443-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice