Provider Demographics
NPI:1699770479
Name:FOSSE, BRIAN THOMAS (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
Last Name:FOSSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 N CAUSEWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3302
Mailing Address - Country:US
Mailing Address - Phone:231-744-3700
Mailing Address - Fax:
Practice Address - Street 1:162 N CAUSEWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3302
Practice Address - Country:US
Practice Address - Phone:231-744-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI120441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4048960Medicaid