Kevin Donald Prush, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

015251 Issued in MI

Practice address

30231 Jefferson Ave
Saint Clair Shores, MI 48082-1787

Phone

(586) 775-2400

Fax

(586) 775-2406

NPI assigned

Apr 13, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: kprush1145150@direct.hfhs.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Diversified Dental, P.C.

  • Dental Clinic/Center
  • Saint Clair Shores, MI
  • NPI 1669191342
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144886400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1661385600000",
    "number": "1982668372",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "30231 JEFFERSON AVE",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480821787",
            "telephone_number": "586-775-2400",
            "fax_number": "586-775-2406"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30231 JEFFERSON AVE",
            "city": "SAINT CLAIR SHORES",
            "state": "MI",
            "postal_code": "480821787",
            "telephone_number": "586-775-2400",
            "fax_number": "586-775-2406"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PRUSH",
        "first_name": "KEVIN",
        "middle_name": "DONALD",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-04-13",
        "last_updated": "2022-08-25",
        "certification_date": "2022-08-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "015251",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Professional Dental Alliance of Michigan, LLC
• Professional Dietitian Services, LLC
• Professional Hearing Aid Center
• Project Wellness LLC
• Project Wellness, LLC
• Gabrielle Elizabeth Pryor
• Sandra J Prytula
• Kristin Psink
• Psy-Che PLLC
• Psychiatric Healing, PLLC

• General Practice Dentistry in Saint Clair Shores, MI
• Providers in Saint Clair Shores, MI by specialty
• General Practice Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.