Provider Demographics
NPI:1235312570
Name:WYANDOTTE OPTICAL,P.C.
Entity Type:Organization
Organization Name:WYANDOTTE OPTICAL,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-282-5030
Mailing Address - Street 1:3101 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-5915
Mailing Address - Country:US
Mailing Address - Phone:734-282-5030
Mailing Address - Fax:
Practice Address - Street 1:3101 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-5915
Practice Address - Country:US
Practice Address - Phone:734-282-5030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002491332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900H266940OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI4624620001Medicare NSC
MI900H266940OtherBLUE CROSS BLUE SHIELD OF MICHIGAN