Provider Demographics
NPI:1437758398
Name:PRISTINE DENTAL CARE
Entity Type:Organization
Organization Name:PRISTINE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:229-740-3890
Mailing Address - Street 1:4733 WOBURN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1767
Mailing Address - Country:US
Mailing Address - Phone:229-740-3890
Mailing Address - Fax:
Practice Address - Street 1:3021 E WALTON BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2368
Practice Address - Country:US
Practice Address - Phone:229-740-3890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty