Provider Demographics
NPI:1366826182
Name:A1 FAMILY DENTISTRY OF LICOLN PARK,PLC
Entity Type:Organization
Organization Name:A1 FAMILY DENTISTRY OF LICOLN PARK,PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANEEL
Authorized Official - Middle Name:KAURR
Authorized Official - Last Name:RANDHAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-226-0638
Mailing Address - Street 1:50481 KOSS DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-6320
Mailing Address - Country:US
Mailing Address - Phone:586-226-0638
Mailing Address - Fax:
Practice Address - Street 1:3830 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-4107
Practice Address - Country:US
Practice Address - Phone:586-226-0638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010191991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty