Provider Demographics
NPI:1598977795
Name:DONALD J. BROCKRIEDE, D.D.S., P.C.
Entity Type:Organization
Organization Name:DONALD J. BROCKRIEDE, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:BROCKRIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-688-3008
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010543261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID105430OtherBCBS OF MICH. DENTAL PROV
MI5446023OtherBCBS MEDICAL PROVIDER