Provider Demographics
NPI: | 1033248000 |
---|---|
Name: | B.D.G.OPTICS, INC |
Entity Type: | Organization |
Organization Name: | B.D.G.OPTICS, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | BRADLEY |
Authorized Official - Middle Name: | DEAN |
Authorized Official - Last Name: | GOLDBERG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 248-674-4065 |
Mailing Address - Street 1: | 4470 HIGHLAND RD |
Mailing Address - Street 2: | |
Mailing Address - City: | WATERFORD |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48328-1222 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-674-4065 |
Mailing Address - Fax: | 248-673-4428 |
Practice Address - Street 1: | 4470 HIGHLAND RD |
Practice Address - Street 2: | |
Practice Address - City: | WATERFORD |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48328-1222 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-674-4065 |
Practice Address - Fax: | 248-673-4428 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-05 |
Last Update Date: | 2021-04-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4901002961 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Single Specialty |