Provider Demographics
NPI:1609139302
Name:PUTMAN, BRIAN JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:PUTMAN
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 1:610 N. PINE RIVER ST.
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847
Mailing Address - Country:US
Mailing Address - Phone:989-875-2888
Mailing Address - Fax:989-875-4604
Practice Address - Street 1:610 N. PINE RIVER ST.
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847
Practice Address - Country:US
Practice Address - Phone:989-875-2888
Practice Address - Fax:989-875-4604
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023756122300000X
MI2901021388122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist