Basic Information
| Provider Information | |||||||||
| NPI: | 1316254881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405324858 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1408 CAMPBELL DR | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405349231 | ||||||||
| FaxNumber: | 7405349378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30.023328 | OH | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 3810027906 | 05 | WV | MEDICAID | 3068522 | 05 | OH | MEDICAID | 30.023328 | 01 | OH | OHIO STATE DENTAL BOARD | OTHER | 7100308330 | 05 | KY | MEDICAID |