Provider Demographics
NPI:1437550514
Name:ST. VINCENT DE PAUL DETROIT DENTAL
Entity Type:Organization
Organization Name:ST. VINCENT DE PAUL DETROIT DENTAL
Other - Org Name:ST. VINCENT DE PAUL DETROIT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARMON
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:313-393-3009
Mailing Address - Street 1:3505 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5633
Mailing Address - Country:US
Mailing Address - Phone:248-765-4665
Mailing Address - Fax:
Practice Address - Street 1:3000 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2372
Practice Address - Country:US
Practice Address - Phone:313-942-5957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SOCIETY OF ST. VINCENT DE PAUL IN THE ARCHDIOCESE OF DETROIT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902017311261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental