Healthcare Provider Details

I. General information

NPI: 1285846451
Provider Name (Legal Business Name): DONALD JOE BROCKRIEDE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 HURON ST
NORTH BRANCH MI
48461-8117
US

IV. Provider business mailing address

PO BOX 707
NORTH BRANCH MI
48461-0707
US

V. Phone/Fax

Practice location:
  • Phone: 810-688-3008
  • Fax: 810-688-2429
Mailing address:
  • Phone: 810-688-3008
  • Fax: 810-688-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901010543
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: