Provider Demographics
NPI:1013216639
Name:PROSTHETIC AND IMPLANTS DENTISTRY PC
Entity Type:Organization
Organization Name:PROSTHETIC AND IMPLANTS DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-399-8600
Mailing Address - Street 1:1206 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3222
Mailing Address - Country:US
Mailing Address - Phone:248-399-8600
Mailing Address - Fax:248-399-8613
Practice Address - Street 1:1206 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3222
Practice Address - Country:US
Practice Address - Phone:248-399-8600
Practice Address - Fax:248-399-8613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010196371223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty