Provider Demographics
NPI:1407887656
Name:PROVIDENT DENTISTRY
Entity Type:Organization
Organization Name:PROVIDENT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:KESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-471-0345
Mailing Address - Street 1:40105 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2170
Mailing Address - Country:US
Mailing Address - Phone:248-471-0345
Mailing Address - Fax:248-471-0671
Practice Address - Street 1:40105 GRAND RIVER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2170
Practice Address - Country:US
Practice Address - Phone:248-471-0345
Practice Address - Fax:248-471-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12 2753487Medicaid