Provider Demographics
NPI:1093099392
Name:ERIC W. BRUST DDS PC
Entity Type:Organization
Organization Name:ERIC W. BRUST DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:313-299-9700
Mailing Address - Street 1:2355 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3852
Mailing Address - Country:US
Mailing Address - Phone:734-662-7200
Mailing Address - Fax:734-662-7220
Practice Address - Street 1:2355 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3852
Practice Address - Country:US
Practice Address - Phone:734-662-7200
Practice Address - Fax:734-662-7220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI155471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty