Provider Demographics
NPI:1275130908
Name:BERTILRUD, ERIK MIKKEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIK
Middle Name:MIKKEL
Last Name:BERTILRUD
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 1:2459 MEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2630
Mailing Address - Country:US
Mailing Address - Phone:517-899-2442
Mailing Address - Fax:734-818-1473
Practice Address - Street 1:254 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2916
Practice Address - Country:US
Practice Address - Phone:734-676-1333
Practice Address - Fax:734-818-1473
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016007091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice