Provider Demographics
NPI:1285846451
Name:BROCKRIEDE, DONALD JOE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JOE
Last Name:BROCKRIEDE
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:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461-0707
Mailing Address - Country:US
Mailing Address - Phone:810-688-3008
Mailing Address - Fax:810-688-2429
Practice Address - Street 1:3720 HURON ST
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461-8117
Practice Address - Country:US
Practice Address - Phone:810-688-3008
Practice Address - Fax:810-688-2429
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010105431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice