Provider Demographics
NPI:1114366234
Name:SUBURBAN FAMILY DENTAL
Entity Type:Organization
Organization Name:SUBURBAN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-685-7273
Mailing Address - Street 1:2725 S MILFORD RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48357
Mailing Address - Country:US
Mailing Address - Phone:248-685-7273
Mailing Address - Fax:248-685-1394
Practice Address - Street 1:2725 S MILFORD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357
Practice Address - Country:US
Practice Address - Phone:248-685-7273
Practice Address - Fax:248-685-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014830261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Other1223G0001X DENTAL OFFICE