Provider Demographics
NPI:1366635146
Name:YOUR FAMILY DENTIST PC
Entity Type:Organization
Organization Name:YOUR FAMILY DENTIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-423-9000
Mailing Address - Street 1:28245 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2863
Mailing Address - Country:US
Mailing Address - Phone:248-423-9000
Mailing Address - Fax:248-423-9020
Practice Address - Street 1:28245 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2863
Practice Address - Country:US
Practice Address - Phone:248-423-9000
Practice Address - Fax:248-423-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty