=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619036613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS BURAU PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 E GRAND BLANC RD
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-694-8244
-----------------------------------------------------
Fax | 810-694-4285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 E GRAND BLANC RD
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-694-8244
-----------------------------------------------------
Fax | 810-694-4285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. BRADLEY ALLEN BURAU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 810-694-8244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901015019
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901017041
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901015751
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------