MEDICARE: DR. BRIAN THOMAS FOSSE DDS

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	12044	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699770479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN THOMAS FOSSE DDS

Provider Business Mailing Address
First Line	:	162 N CAUSEWAY ST
Second Line	:
City	:	NORTH MUSKEGON
State	:	MI
Zip	:	49445-3302
Country	:	US
Telephone Number	:	231-744-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	162 N CAUSEWAY ST
Second Line	:
City	:	NORTH MUSKEGON
State	:	MI
Zip	:	49445-3302
Country	:	US
Telephone Number	:	231-744-3700
Fax Number	:

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	07/08/2007

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