Healthcare Provider Details

I. General information

NPI: 1811663982
Provider Name (Legal Business Name): BEULAH FAMILY DENTISTRY , PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 08/19/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 BEULAH HWY
BEULAH MI
49617-8708
US

IV. Provider business mailing address

3986 HEATHERWOOD DR E
TRAVERSE CITY MI
49684-8615
US

V. Phone/Fax

Practice location:
  • Phone: 248-974-8978
  • Fax:
Mailing address:
  • Phone: 248-974-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSHUA SHAW BRUDI
Title or Position: DENTIST OWNER
Credential: DDS
Phone: 248-974-8978