Provider Demographics
NPI:1386793685
Name:HUSBECK, EDWARD ALEX JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALEX
Last Name:HUSBECK
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 WOOD VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9714
Mailing Address - Country:US
Mailing Address - Phone:517-339-9235
Mailing Address - Fax:
Practice Address - Street 1:200 N HOMER ST
Practice Address - Street 2:SUITE B
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4741
Practice Address - Country:US
Practice Address - Phone:517-333-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI102311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4004966Medicaid