Provider Demographics
NPI:1962657171
Name:BROOKS, DONALD WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WILSON
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 CASS STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109
Mailing Address - Country:US
Mailing Address - Phone:858-483-3302
Mailing Address - Fax:858-483-3180
Practice Address - Street 1:4655 CASS ST.
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:858-483-3302
Practice Address - Fax:858-483-3180
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD20506122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist