Provider Demographics
NPI:1629414255
Name:LIVINGSTON DENTAL SLEEP THERAPY PLLC
Entity Type:Organization
Organization Name:LIVINGSTON DENTAL SLEEP THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-227-4224
Mailing Address - Street 1:8641 W GRAND RIVER AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-4353
Mailing Address - Country:US
Mailing Address - Phone:810-227-4224
Mailing Address - Fax:810-227-4660
Practice Address - Street 1:8641 W GRAND RIVER AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-4353
Practice Address - Country:US
Practice Address - Phone:810-227-4224
Practice Address - Fax:810-227-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10174122300000X
MI17224122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty