Provider Demographics
NPI:1265682900
Name:OLDE ORCHARD PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:OLDE ORCHARD PEDIATRIC DENTISTRY
Other - Org Name:SUSAN H. CARRON, D.D.S., M.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAPHNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-478-3232
Mailing Address - Street 1:40105 GRAND RIVER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2170
Mailing Address - Country:US
Mailing Address - Phone:248-478-3232
Mailing Address - Fax:
Practice Address - Street 1:40105 GRAND RIVER AVE STE 2
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2170
Practice Address - Country:US
Practice Address - Phone:248-478-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010115391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2669122Medicaid
MI2823071Medicaid