Provider Demographics
NPI:1205030277
Name:RENAISSANCE DENTAL PC
Entity Type:Organization
Organization Name:RENAISSANCE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-340-9293
Mailing Address - Street 1:7330 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-1041
Mailing Address - Country:US
Mailing Address - Phone:313-340-9293
Mailing Address - Fax:313-340-9293
Practice Address - Street 1:7330 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-1041
Practice Address - Country:US
Practice Address - Phone:313-340-9293
Practice Address - Fax:313-340-9293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI128811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty