Active NPI
Bruce A Mickelson, DDS
- Dentist
- Grand Rapids, MI
National Provider Identifier
1760555692
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 11496
- Practice address
- 976 3 Mile Rd NW
Grand Rapids, MI 49544 - Phone
- (616) 784-4038
- Fax
- (616) 785-9501
- NPI assigned
- Nov 16, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 11496 | MI | Primary |
Addresses
Primary practice location
976 3 Mile Rd NW
Grand Rapids, MI 49544
Mailing address
976 3 Mile Rd NW
Grand Rapids, MI 49544
Phone (616) 784-4038
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11496 | MI | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163635200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1760555692",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "976 3 MILE RD NW",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49544",
"telephone_number": "616-784-4038",
"fax_number": "616-785-9501"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "976 3 MILE RD NW",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49544",
"telephone_number": "616-784-4038",
"fax_number": "616-785-9501"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MICKELSON",
"first_name": "BRUCE",
"middle_name": "A",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-16",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MI",
"license": "11496",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.