Provider Demographics
NPI:1861503328
Name:BRUSTAD, ROBERT A (DDS MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:BRUSTAD
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 EAST STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104
Mailing Address - Country:US
Mailing Address - Phone:734-665-3404
Mailing Address - Fax:
Practice Address - Street 1:1111 EAST STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104
Practice Address - Country:US
Practice Address - Phone:734-665-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9733122300000X
MI5171223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0700XDental ProvidersDentistProsthodontics