Provider Demographics
NPI:1356685275
Name:PETER BRZOZA, LLC
Entity Type:Organization
Organization Name:PETER BRZOZA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRZOZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-496-2087
Mailing Address - Street 1:1284 BEACON ST
Mailing Address - Street 2:APT# 202
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3788
Mailing Address - Country:US
Mailing Address - Phone:347-496-2087
Mailing Address - Fax:
Practice Address - Street 1:1284 BEACON STREET
Practice Address - Street 2:APT# 202
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446
Practice Address - Country:US
Practice Address - Phone:347-496-2087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18556701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty