=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053930594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANNE NICOLE FERGUSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2020
-----------------------------------------------------
Last Update Date | 03/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 SEMINOLE RD STE 101
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-6561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-780-3200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 SEMINOLE RD STE 101
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-6561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-780-3200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2901600714
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------