Provider Demographics
NPI:1083016711
Name:SPECIAL DENTAL PC
Entity Type:Organization
Organization Name:SPECIAL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REG MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-342-1997
Mailing Address - Street 1:27201 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5127
Mailing Address - Country:US
Mailing Address - Phone:586-558-8004
Mailing Address - Fax:
Practice Address - Street 1:27201 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-558-8004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty