Healthcare Provider Details

I. General information

NPI: 1598977795
Provider Name (Legal Business Name): DONALD J. BROCKRIEDE, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number2901010543
License Number StateMI

VIII. Authorized Official

Name: DR. DONALD JOE BROCKRIEDE
Title or Position: OFFICER
Credential: D.D.S.
Phone: 810-688-3008