Provider Demographics
NPI:1841620655
Name:FOWLERVILLE FAMILY DENTISTRY
Entity type:Organization
Organization Name:FOWLERVILLE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-223-8545
Mailing Address - Street 1:753 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-7914
Mailing Address - Country:US
Mailing Address - Phone:517-223-8545
Mailing Address - Fax:517-223-8505
Practice Address - Street 1:753 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-7914
Practice Address - Country:US
Practice Address - Phone:517-223-8545
Practice Address - Fax:517-223-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017224122300000X
MI2901020477122300000X
MI2901010174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty