Provider Demographics
NPI:1477230522
Name:WILSON, BROOKE MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8841 BUTTERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1440
Mailing Address - Country:US
Mailing Address - Phone:773-837-1110
Mailing Address - Fax:
Practice Address - Street 1:12130 S HARLEM AVE STE B
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1459
Practice Address - Country:US
Practice Address - Phone:708-728-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist