=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598141087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROCKTON WILLEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2015
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 CROSWELL AVE. SE
-----------------------------------------------------
City | EAST GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-8842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-266-2611
-----------------------------------------------------
Fax | 616-282-1709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 CROSWELL AVE. SE
-----------------------------------------------------
City | EAST GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-266-2611
-----------------------------------------------------
Fax | 616-282-1709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019030407
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------