Provider Demographics
NPI:1285813832
Name:ASPEN DENTAL OF MICHIGAN PC
Entity Type:Organization
Organization Name:ASPEN DENTAL OF MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:281 SANDERS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4391 CANAL AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2680
Practice Address - Country:US
Practice Address - Phone:616-530-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty