Basic Information
| Provider Information | |||||||||
| NPI: | 1932106564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEABODY | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 S. GETTY STREET | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317679830 | ||||||||
| FaxNumber: | 2317732454 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 S. GETTY STREET | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON HTS. | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317679830 | ||||||||
| FaxNumber: | 2317732454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901011507 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 12-3138796 | 05 | MI | MEDICAID | 115070 | 01 | MI | DENTAL PROVIDER BCBS | OTHER | 443416 | 01 | MI | DENTAL PRVDR.# FOR UCCI | OTHER | 12-4044943 | 05 | MI | MEDICAID | 913785 | 01 | MI | DENTAL PRVDR.# FOR UCCI | OTHER |