Provider Demographics
NPI:1871236513
Name:NYGAARD, BROOKE LOUISE (DMD)
Entity type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:LOUISE
Last Name:NYGAARD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:LOUISE
Other - Last Name:WILDER-CORRIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 ARBUTUS AVE
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-2004
Mailing Address - Country:US
Mailing Address - Phone:920-516-7107
Mailing Address - Fax:
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-2004
Practice Address - Country:US
Practice Address - Phone:920-516-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTDEN-DEN-LIC-23658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program