Provider Demographics
NPI:1285003905
Name:TMJ AND SLEEP OF SE MICHIGAN
Entity Type:Organization
Organization Name:TMJ AND SLEEP OF SE MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-290-2900
Mailing Address - Street 1:36700 WOODWARD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0926
Mailing Address - Country:US
Mailing Address - Phone:248-290-2900
Mailing Address - Fax:
Practice Address - Street 1:36700 WOODWARD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48304-0926
Practice Address - Country:US
Practice Address - Phone:248-290-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental