MEDICARE: DONALD J. BROCKRIEDE, D.D.S., P.C.

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	261QD0000X	Dental Clinic/Center	2901010543	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D105430	OTHER	MI	BCBS OF MICH. DENTAL PROV
2	5446023	OTHER	MI	BCBS MEDICAL PROVIDER

General Provider Information

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

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	:	OFFICER
Name	:	DR. DONALD JOE BROCKRIEDE
Credential	:	D.D.S.
Telephone Number	:	810-688-3008

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/22/2020

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