Provider Demographics
NPI:1801467352
Name:BREJNAK, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BREJNAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 JASMOND RD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9676
Mailing Address - Country:US
Mailing Address - Phone:810-358-5212
Mailing Address - Fax:
Practice Address - Street 1:9096 DAVISON RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1037
Practice Address - Country:US
Practice Address - Phone:810-653-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5307010959122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist