Provider Demographics
NPI:1245642826
Name:HABECKER, BRENTON DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:DAVID
Last Name:HABECKER
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 1:15032 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-9484
Mailing Address - Country:US
Mailing Address - Phone:269-744-0093
Mailing Address - Fax:
Practice Address - Street 1:529 N GRAND ST
Practice Address - Street 2:
Practice Address - City:SCHOOLCRAFT
Practice Address - State:MI
Practice Address - Zip Code:49087-9128
Practice Address - Country:US
Practice Address - Phone:269-679-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist