MEDICARE: DR. DONALD JOE BROCKRIEDE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901010543	MI

General Provider Information

NPI Number	:	1285846451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD JOE BROCKRIEDE D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 707
Second Line	:
City	:	NORTH BRANCH
State	:	MI
Zip	:	48461-0707
Country	:	US
Telephone Number	:	810-688-3008
Fax Number	:	810-688-2429

Provider Business Practice Location Address
First Line	:	3720 HURON ST
Second Line	:
City	:	NORTH BRANCH
State	:	MI
Zip	:	48461-8117
Country	:	US
Telephone Number	:	810-688-3008
Fax Number	:	810-688-2429

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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