Provider Demographics
NPI:1275584732
Name:PRUDHOMME, MICHAEL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:PRUDHOMME
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 1:5760 CLARKSTON RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4706
Mailing Address - Country:US
Mailing Address - Phone:248-625-9001
Mailing Address - Fax:248-625-8729
Practice Address - Street 1:5760 CLARKSTON RD.
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4706
Practice Address - Country:US
Practice Address - Phone:248-625-9001
Practice Address - Fax:248-625-8729
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI118541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice