Provider Demographics
NPI:1225602022
Name:CHILDRENS DENTAL PROGRAM PLLC
Entity Type:Organization
Organization Name:CHILDRENS DENTAL PROGRAM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IFECHIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:NWABUEZR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-217-7997
Mailing Address - Street 1:22241 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1716
Mailing Address - Country:US
Mailing Address - Phone:248-217-7997
Mailing Address - Fax:
Practice Address - Street 1:22241 JOHN R RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1716
Practice Address - Country:US
Practice Address - Phone:248-217-7997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty