Provider Demographics
NPI:1366504078
Name:BROWN, MICHELLE BRENDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:BRENDA
Last Name:BROWN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:BRENDA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:901 VERNE LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1128
Mailing Address - Country:US
Mailing Address - Phone:773-835-0427
Mailing Address - Fax:
Practice Address - Street 1:567 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-283-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011745A122300000X, 1223G0001X
IL0190230141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist