Provider Demographics
NPI:1558472357
Name:PROFFITT, BRIAN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:PROFFITT
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 1:200 CLEVELAND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-5652
Mailing Address - Country:US
Mailing Address - Phone:563-264-8970
Mailing Address - Fax:563-263-6791
Practice Address - Street 1:200 CLEVELAND ST
Practice Address - Street 2:SUITE B
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-5652
Practice Address - Country:US
Practice Address - Phone:563-264-8970
Practice Address - Fax:563-263-6791
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA65871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice