Provider Demographics
NPI:1508532599
Name:DEWILDE, BRIAN PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PETER
Last Name:DEWILDE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2479 CEDAR CANYON RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6696
Mailing Address - Country:US
Mailing Address - Phone:616-485-2354
Mailing Address - Fax:
Practice Address - Street 1:4294 MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1226
Practice Address - Country:US
Practice Address - Phone:470-231-5272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9077111N00000X
GACHIR010554111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor