Provider Demographics
NPI:1942812300
Name:HOUSTON, BROOKE BRACY (DMD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:BRACY
Last Name:HOUSTON
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 1:4561 MAINE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305
Mailing Address - Country:US
Mailing Address - Phone:217-228-1085
Mailing Address - Fax:217-228-1089
Practice Address - Street 1:4561 MAINE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305
Practice Address - Country:US
Practice Address - Phone:217-228-1085
Practice Address - Fax:217-228-1089
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190327131223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice