Provider Demographics
NPI:1255482659
Name:CODY DENTAL CENTER P.C.
Entity Type:Organization
Organization Name:CODY DENTAL CENTER P.C.
Other - Org Name:DR. KAREN E. EGGLESTON
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-395-4700
Mailing Address - Street 1:17070 W 12 MILE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2116
Mailing Address - Country:US
Mailing Address - Phone:248-395-4700
Mailing Address - Fax:
Practice Address - Street 1:17070 W 12 MILE RD
Practice Address - Street 2:SUITE C
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2116
Practice Address - Country:US
Practice Address - Phone:248-395-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI131021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ131020OtherBLUE CROSS BLUE SHIELD