Healthcare Provider Details

I. General information

NPI: 1386196798
Provider Name (Legal Business Name): BRADLEY J. GAUTHIER, DDS, MS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 09/06/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W UNIVERSITY DR # 101
ROCHESTER MI
48307-1873
US

IV. Provider business mailing address

48309 MAPLEHURST DR
SHELBY TOWNSHIP MI
48317-2788
US

V. Phone/Fax

Practice location:
  • Phone: 248-656-0040
  • Fax:
Mailing address:
  • Phone: 906-399-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901021816
License Number StateMI

VIII. Authorized Official

Name: LAUREN GAUTHIER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 906-399-0342