Provider Demographics
NPI:1679693840
Name:BROSTOWITZ, DAVID RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:BROSTOWITZ
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 1:141 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1421
Mailing Address - Country:US
Mailing Address - Phone:715-582-3601
Mailing Address - Fax:
Practice Address - Street 1:141 W FRONT ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1421
Practice Address - Country:US
Practice Address - Phone:715-582-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00031701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33452900Medicaid