Provider Demographics
NPI:1982011771
Name:BULLARD, BRETT
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:BULLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20075 NORTHVILLE PLACE DR APT 3122
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2962
Mailing Address - Country:US
Mailing Address - Phone:810-577-8916
Mailing Address - Fax:
Practice Address - Street 1:20075 NORTHVILLE PLACE DR APT 3122
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-2962
Practice Address - Country:US
Practice Address - Phone:810-577-8916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010213671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice