Provider Demographics
NPI:1003929662
Name:THE DENTAL CLINIC PC
Entity Type:Organization
Organization Name:THE DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-386-9660
Mailing Address - Street 1:1359 CHAMPAIGN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3303
Mailing Address - Country:US
Mailing Address - Phone:313-386-9660
Mailing Address - Fax:313-386-5515
Practice Address - Street 1:1359 CHAMPAIGN
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3303
Practice Address - Country:US
Practice Address - Phone:313-386-9660
Practice Address - Fax:313-386-5515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1958213740OtherBLUE CROSS MEDICAL