Healthcare Provider Details

I. General information

NPI: 1538385869
Provider Name (Legal Business Name): ERIC W. BRUST DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10460 PELHAM RD
TAYLOR MI
48180-3828
US

IV. Provider business mailing address

10460 PELHAM RD
TAYLOR MI
48180-3828
US

V. Phone/Fax

Practice location:
  • Phone: 313-299-9700
  • Fax: 313-299-9951
Mailing address:
  • Phone: 313-299-9700
  • Fax: 313-299-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number15547
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: