Provider Demographics
NPI:1073637682
Name:BULTHUIS, PETER L (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:L
Last Name:BULTHUIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8578 GOLFSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-2217
Mailing Address - Country:US
Mailing Address - Phone:248-561-6171
Mailing Address - Fax:734-422-1335
Practice Address - Street 1:5625 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2457
Practice Address - Country:US
Practice Address - Phone:734-422-1332
Practice Address - Fax:734-422-1335
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010132461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice