Provider Demographics
NPI:1093245540
Name:BRUDI, JOSHUA SHAW (DDS)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:SHAW
Last Name:BRUDI
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 1:3986 HEATHERWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8615
Mailing Address - Country:US
Mailing Address - Phone:248-974-8978
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY
Practice Address - Street 2:
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616
Practice Address - Country:US
Practice Address - Phone:231-383-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010222981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice