Provider Demographics
NPI:1932466489
Name:FUKUOKA, BROOKE MARIE-OSGOOD
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:MARIE-OSGOOD
Last Name:FUKUOKA
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:BROOKE
Other - Middle Name:MARIE-OSGOOD
Other - Last Name:FUKUOKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1508 N LYNDON ST
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:826 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6858
Practice Address - Country:US
Practice Address - Phone:208-732-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-45331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID131812Medicare Oscar/Certification