Mark James Broomhead, DDS
Individual provider Active NPI General Practice Dentistry · South Holland, IL
NPI 1831531706 · NPPES record last updated Jul 22, 2013
Key facts
- NPI
- 1831531706
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 019026740 (IL)
- Practice address
- 615 E 162ND St
South Holland, IL 60473-2329 - Phone
- (773) 817-5500
- NPI assigned
- Jul 22, 2013
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150615000677 | IN | Order and Referring Only - Dentist |
6002127289 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019026740 | IL | MD | General Practice Dentistry |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 019026740 | IL | Yes |
Addresses
Primary practice location
615 E 162ND St
South Holland, IL 60473-2329
Mailing address
615 E 162ND St
South Holland, IL 60473-2329
Phone (773) 817-5500
Other providers in South Holland, IL
- Branc Mobility Inc
- Jeffrey W Branta
- Gail Briggs
- Dale Steven Brink
- Jahmiaa C Brooks
- Josalynn M Brown
- Latoya Brown
- Bonnie Brownlee
- Lauren Bryant
- Peyton Cecilia Burke
All providers in South Holland, IL · General Practice Dentistry in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 22, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.