Provider Demographics
NPI:1558095786
Name:ASH, BROOKE ASHLEY
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:ASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12665 W 28TH PL
Mailing Address - Street 2:
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60099-9735
Mailing Address - Country:US
Mailing Address - Phone:847-553-6898
Mailing Address - Fax:
Practice Address - Street 1:1320 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4402
Practice Address - Country:US
Practice Address - Phone:262-223-0280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10755-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist