Provider Demographics
NPI:1336795079
Name:NADEAU, BRIAN PETER (DMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PETER
Last Name:NADEAU
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 1:23RD DENTAL COMPANY
Mailing Address - Street 2:1591 GRIFFIN ROAD
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278
Mailing Address - Country:US
Mailing Address - Phone:413-221-8386
Mailing Address - Fax:
Practice Address - Street 1:23RD DENTAL COMPANY
Practice Address - Street 2:1591 GRIFFIN ROAD
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:413-221-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18584031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics