Provider Demographics
NPI:1093264731
Name:SOUTHFIELD KIDS DENTIST PLC
Entity Type:Organization
Organization Name:SOUTHFIELD KIDS DENTIST PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IFECHIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:NWABUEZE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-217-7997
Mailing Address - Street 1:18900 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2669
Mailing Address - Country:US
Mailing Address - Phone:248-565-3332
Mailing Address - Fax:
Practice Address - Street 1:18900 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2669
Practice Address - Country:US
Practice Address - Phone:248-565-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010202601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty