MEDICARE: BROOKE MARIE WILSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019.034343	IL

General Provider Information

NPI Number	:	1477230522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE MARIE WILSON DMD

Provider Business Mailing Address
First Line	:	8841 BUTTERFIELD LN
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-1440
Country	:	US
Telephone Number	:	773-837-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	12130 S HARLEM AVE STE B
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1459
Country	:	US
Telephone Number	:	708-728-3300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2023
Last Update Date	:	06/30/2023

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Directions to “ BROOKE MARIE WILSON DMD” Practice Location

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