Healthcare Provider Details

I. General information

NPI: 1558602797
Provider Name (Legal Business Name): KYLE JAKOB THORSRUD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19249 ALLEN RD
BROWNSTOWN TWP MI
48183-1189
US

IV. Provider business mailing address

19249 ALLEN RD
BROWNSTOWN TWP MI
48183-1189
US

V. Phone/Fax

Practice location:
  • Phone: 734-479-2990
  • Fax: 734-479-2991
Mailing address:
  • Phone: 734-479-2990
  • Fax: 734-479-2991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901020250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: