Provider Demographics
NPI:1033548201
Name:CONVENIENT BR PC
Entity Type:Organization
Organization Name:CONVENIENT BR PC
Other - Org Name:DISTINCTIVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. TO GEN. MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MASCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-542-9700
Mailing Address - Street 1:2120 GRAND RIVER ANX
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7392
Mailing Address - Country:US
Mailing Address - Phone:810-225-0022
Mailing Address - Fax:810-225-0033
Practice Address - Street 1:2120 GRAND RIVER ANX
Practice Address - Street 2:SUITE 100
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7392
Practice Address - Country:US
Practice Address - Phone:810-225-0022
Practice Address - Fax:810-225-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty