Provider Demographics
NPI:1164893392
Name:REDWOOD DENTAL GROUP
Entity Type:Organization
Organization Name:REDWOOD DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOUCHILLON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1586-979-2800
Mailing Address - Street 1:255 W 13 MILE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1868
Mailing Address - Country:US
Mailing Address - Phone:734-722-5130
Mailing Address - Fax:734-722-5192
Practice Address - Street 1:6511 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1653
Practice Address - Country:US
Practice Address - Phone:248-577-5188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty