Healthcare Provider Details

I. General information

NPI: 1093099392
Provider Name (Legal Business Name): ERIC W. BRUST DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 W STADIUM BLVD
ANN ARBOR MI
48103-3852
US

IV. Provider business mailing address

2355 W STADIUM BLVD
ANN ARBOR MI
48103-3852
US

V. Phone/Fax

Practice location:
  • Phone: 734-662-7200
  • Fax: 734-662-7220
Mailing address:
  • Phone: 734-662-7200
  • Fax: 734-662-7220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number15547
License Number StateMI

VIII. Authorized Official

Name: ERIC W BRUST
Title or Position: PRESIDENT
Credential: DDS MS
Phone: 313-299-9700