Provider Demographics
NPI:1306032511
Name:NORTH OAKLAND DENTAL CENTER
Entity Type:Organization
Organization Name:NORTH OAKLAND DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-333-2424
Mailing Address - Street 1:35 S JOHNSON ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1658
Mailing Address - Country:US
Mailing Address - Phone:248-333-2424
Mailing Address - Fax:248-623-1252
Practice Address - Street 1:35 S JOHNSON ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1658
Practice Address - Country:US
Practice Address - Phone:248-333-2424
Practice Address - Fax:248-623-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010078921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2810761Medicaid