Provider Demographics
NPI:1265863021
Name:TOTAL DENTAL FITNESS
Entity Type:Organization
Organization Name:TOTAL DENTAL FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MAYLATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-642-5020
Mailing Address - Street 1:50 W BIG BEAVER RD
Mailing Address - Street 2:STE 120
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3910
Mailing Address - Country:US
Mailing Address - Phone:248-642-5020
Mailing Address - Fax:
Practice Address - Street 1:50 W BIG BEAVER RD
Practice Address - Street 2:STE 120
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3910
Practice Address - Country:US
Practice Address - Phone:248-642-5020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI147671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty