Provider Demographics
NPI:1003100470
Name:BROTKOWSKI, EDDIE KIYOSHI (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:KIYOSHI
Last Name:BROTKOWSKI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 W KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5011
Mailing Address - Country:US
Mailing Address - Phone:847-612-3407
Mailing Address - Fax:
Practice Address - Street 1:464 S HICKORY ST STE A
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5531
Practice Address - Country:US
Practice Address - Phone:920-923-0111
Practice Address - Fax:920-923-0366
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI10017671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program