Provider Demographics
NPI:1194894139
Name:BROOKS, CRYSTAL ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:ANN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2455
Mailing Address - Country:US
Mailing Address - Phone:262-284-5788
Mailing Address - Fax:262-268-8284
Practice Address - Street 1:1032 S SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2455
Practice Address - Country:US
Practice Address - Phone:262-284-5788
Practice Address - Fax:262-268-8284
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2596122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist