Provider Demographics
NPI:1508028820
Name:BROOKES, CAROLYN C (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:C
Last Name:BROOKES
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:CASSIDY
Other - Last Name:DICUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5760
Mailing Address - Fax:414-259-9115
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5760
Practice Address - Fax:414-259-9115
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1506611223S0112X
WI64325204E00000X
WI10011681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508028820Medicaid