Provider Demographics
NPI:1083708648
Name:DEGISE, BRIAN R (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:DEGISE
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W CANDLETREE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1586
Mailing Address - Country:US
Mailing Address - Phone:309-691-9171
Mailing Address - Fax:309-693-6471
Practice Address - Street 1:1318 W CANDLETREE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1586
Practice Address - Country:US
Practice Address - Phone:309-691-9171
Practice Address - Fax:309-693-6471
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics