Healthcare Provider Details

I. General information

NPI: 1275130908
Provider Name (Legal Business Name): ERIK MIKKEL BERTILRUD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 W ST JOE HWY # 202
LANSING MI
48917-4088
US

IV. Provider business mailing address

3585 OBSERVATORY LN
HOLT MI
48842-9429
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-1848
  • Fax:
Mailing address:
  • Phone: 517-899-2442
  • Fax: 734-818-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901600709
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: