| NPI | 1629414255 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRIAN J PETERSBURG Owner/Dentist 810-227-4224 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 10174) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 17224) |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment | |
| Enumeration Date | 2013-05-22 |
| Last Update Date | 2013-05-22 |