Basic Information
| Provider Information | |||||||||
| NPI: | 1043222169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | HILTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162357280 | ||||||||
| FaxNumber: | 6167524119 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SHELDON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167762340 | ||||||||
| FaxNumber: | 6167762341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901018414 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | D018414 | 01 | MI | BCBS | OTHER | 4439168 | 05 | MI | MEDICAID | 4439177 | 05 | MI | MEDICAID | D184140 | 01 | MI | BCBS | OTHER | 4547700 | 05 | MI | MEDICAID |