Provider Demographics
NPI:1598141087
Name:WILLEY, BROCKTON
Entity type:Individual
Prefix:
First Name:BROCKTON
Middle Name:
Last Name:WILLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 CROSWELL AVE. SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-266-2611
Mailing Address - Fax:616-282-1709
Practice Address - Street 1:660 CROSWELL AVE. SE
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-8842
Practice Address - Country:US
Practice Address - Phone:616-266-2611
Practice Address - Fax:616-282-1709
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist