Provider Demographics
NPI:1083734958
Name:PETERSBURG, BRIAN JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JON
Last Name:PETERSBURG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-9742
Mailing Address - Country:US
Mailing Address - Phone:810-227-5874
Mailing Address - Fax:810-227-5898
Practice Address - Street 1:8641 W GRAND RIVER AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-4353
Practice Address - Country:US
Practice Address - Phone:810-227-4224
Practice Address - Fax:810-227-4660
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010101741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice