Provider Demographics
NPI:1932106564
Name:PEABODY, CHRISTIAN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:A
Last Name:PEABODY
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 1:2201 S. GETTY STREET
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1207
Mailing Address - Country:US
Mailing Address - Phone:231-767-9830
Mailing Address - Fax:231-773-2454
Practice Address - Street 1:2201 S. GETTY STREET
Practice Address - Street 2:
Practice Address - City:MUSKEGON HTS.
Practice Address - State:MI
Practice Address - Zip Code:49444-1207
Practice Address - Country:US
Practice Address - Phone:231-767-9830
Practice Address - Fax:231-773-2454
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010115071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12-3138796Medicaid
MI115070OtherDENTAL PROVIDER BCBS
MI443416OtherDENTAL PRVDR.# FOR UCCI
MI12-4044943Medicaid
MI913785OtherDENTAL PRVDR.# FOR UCCI