Provider Demographics
NPI:1760555692
Name:MICKELSON, BRUCE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:MICKELSON
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 1:976 3 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544
Mailing Address - Country:US
Mailing Address - Phone:616-784-4038
Mailing Address - Fax:616-785-9501
Practice Address - Street 1:976 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544
Practice Address - Country:US
Practice Address - Phone:616-784-4038
Practice Address - Fax:616-785-9501
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI11496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist