Healthcare Provider Details

I. General information

NPI: 1548423015
Provider Name (Legal Business Name): BRANDON J CHURCHMAN PA-C, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2008
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LAKE EASTBROOK BLVD SE STE 212
GRAND RAPIDS MI
49546-5989
US

IV. Provider business mailing address

4100 EMBASSY DR SE STE 400
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 616-258-1473
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5691005799
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901022201
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: