Provider Demographics
NPI:1205815628
Name:ROYAL OAK FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROYAL OAK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-543-7070
Mailing Address - Street 1:1200 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3222
Mailing Address - Country:US
Mailing Address - Phone:248-543-7070
Mailing Address - Fax:248-543-3520
Practice Address - Street 1:1200 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3222
Practice Address - Country:US
Practice Address - Phone:248-543-7070
Practice Address - Fax:248-543-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0140411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty