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General NPI Number Information
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NPI Number | 1477230522
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Entity Type | Individual
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Provider Name | BROOKE MARIE WILSON DMD
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Gender | Female
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Dates
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Enumeration Date | 06/30/2023
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Last Update Date | 06/30/2023
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Provider Practice Location Address
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Address Line | 12130 S HARLEM AVE STE B
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City | PALOS HEIGHTS
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State | IL
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Zip | 60463-1459
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Country | US
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Telephone | 708-728-3300
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Fax |
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Provider Business Mailing Address
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Address Line | 8841 BUTTERFIELD LN
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City | ORLAND PARK
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State | IL
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Zip | 60462-1440
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Country | US
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Telephone | 773-837-1110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019.034343
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License Number State | IL
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