Healthcare Provider Details

I. General information

NPI: 1386793685
Provider Name (Legal Business Name): EDWARD ALEX HUSBECK JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N HOMER ST SUITE B
LANSING MI
48912-4741
US

IV. Provider business mailing address

5550 WOOD VALLEY DR
HASLETT MI
48840-9714
US

V. Phone/Fax

Practice location:
  • Phone: 517-333-2585
  • Fax:
Mailing address:
  • Phone: 517-339-9235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: