Provider Demographics
NPI:1063748614
Name:PETERS, BRIAN JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAY
Last Name:PETERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MILL ST
Mailing Address - Street 2:
Mailing Address - City:MAXWELL
Mailing Address - State:TX
Mailing Address - Zip Code:78656-4363
Mailing Address - Country:US
Mailing Address - Phone:646-660-0059
Mailing Address - Fax:
Practice Address - Street 1:12501 HYMEADOW DR STE 1A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1831
Practice Address - Country:US
Practice Address - Phone:512-682-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX220231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics