Provider Demographics
NPI:1386829059
Name:KAISER DENTAL PC
Entity Type:Organization
Organization Name:KAISER DENTAL PC
Other - Org Name:SUPERTEETH
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANLEY
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:KAISER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-759-5353
Mailing Address - Street 1:23105 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1622
Mailing Address - Country:US
Mailing Address - Phone:586-759-5353
Mailing Address - Fax:
Practice Address - Street 1:23105 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1622
Practice Address - Country:US
Practice Address - Phone:586-759-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010098471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty