Provider Demographics
NPI:1740038272
Name:WILBOURN, BROOKE KAYLI (RDH, OM)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:KAYLI
Last Name:WILBOURN
Suffix:
Gender:F
Credentials:RDH, OM
Other - Prefix:MISS
Other - First Name:BROOKE
Other - Middle Name:KAYLI
Other - Last Name:WILBOURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:2945 E SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-7435
Mailing Address - Country:US
Mailing Address - Phone:559-759-0987
Mailing Address - Fax:
Practice Address - Street 1:2945 E SIERRA AVE
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-7435
Practice Address - Country:US
Practice Address - Phone:559-759-0987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30819124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist