Healthcare Provider Details

I. General information

NPI: 1912129909
Provider Name (Legal Business Name): ANDREW RICHARD DRERUP DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 BURTON SE
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2074 FEATHERY COURT
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-3541
  • Fax:
Mailing address:
  • Phone: 616-617-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901019067
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12010491A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5254
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: