Provider Demographics
NPI:1295886760
Name:WEISBRUCH, PETER (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WEISBRUCH
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 1:6495 LONGLAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128
Mailing Address - Country:US
Mailing Address - Phone:386-290-0774
Mailing Address - Fax:
Practice Address - Street 1:6495 LONGLAKE DRIVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128
Practice Address - Country:US
Practice Address - Phone:386-290-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL93521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice