Provider Demographics
NPI:1215402383
Name:MICHIGAN DENTAL PC
Entity Type:Organization
Organization Name:MICHIGAN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-674-0384
Mailing Address - Street 1:4626 W WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3535
Mailing Address - Country:US
Mailing Address - Phone:248-674-0384
Mailing Address - Fax:248-674-1483
Practice Address - Street 1:4626 W WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3535
Practice Address - Country:US
Practice Address - Phone:248-674-0384
Practice Address - Fax:248-674-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty