Provider Demographics
NPI:1306014816
Name:ANN ARBOR DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:ANN ARBOR DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:734-971-3368
Mailing Address - Street 1:3100 E EISENHOWER PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-5205
Mailing Address - Country:US
Mailing Address - Phone:734-971-3368
Mailing Address - Fax:734-971-3979
Practice Address - Street 1:3100 E EISENHOWER PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5205
Practice Address - Country:US
Practice Address - Phone:734-971-3368
Practice Address - Fax:734-971-3979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010101131223P0221X
MI29010180961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty