Provider Demographics
NPI:1174695522
Name:ERIC W. BRUST DDS PC
Entity type:Organization
Organization Name:ERIC W. BRUST DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:313-299-9700
Mailing Address - Street 1:10460 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3828
Mailing Address - Country:US
Mailing Address - Phone:313-299-9700
Mailing Address - Fax:313-299-9951
Practice Address - Street 1:10460 PELHAM RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3828
Practice Address - Country:US
Practice Address - Phone:313-299-9700
Practice Address - Fax:313-299-9951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI155471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI123042560OtherCSHCS
MI193998OtherUNITED CONCORDIA