Provider Demographics
NPI:1699010900
Name:DORNBOS, BRIAN DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DANIEL
Last Name:DORNBOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 CREEK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9397
Mailing Address - Country:US
Mailing Address - Phone:616-901-1894
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist