Provider Demographics
NPI:1215058185
Name:PRUDEN, WILLIAM BAILEY III (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BAILEY
Last Name:PRUDEN
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 M 119
Mailing Address - Street 2:STE H
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9373
Mailing Address - Country:US
Mailing Address - Phone:231-251-9083
Mailing Address - Fax:231-308-5941
Practice Address - Street 1:628 PROGRESS ST STE 200
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9383
Practice Address - Country:US
Practice Address - Phone:989-343-1496
Practice Address - Fax:989-343-1498
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086561223G0001X
MI2901020828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7708Medicaid