Provider Demographics
NPI:1194849513
Name:DORFMAN, JACK MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MICHAEL
Last Name:DORFMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30335 13 MILE ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2262
Mailing Address - Country:US
Mailing Address - Phone:248-487-4013
Mailing Address - Fax:248-487-4015
Practice Address - Street 1:30335 13 MILE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2262
Practice Address - Country:US
Practice Address - Phone:248-487-4013
Practice Address - Fax:248-487-4015
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI08393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist