Provider Demographics
NPI:1447402805
Name:WAYNE FAMILY DENTAL ASSOCIATION PC
Entity Type:Organization
Organization Name:WAYNE FAMILY DENTAL ASSOCIATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BHAVANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SWARNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-728-8800
Mailing Address - Street 1:35102 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1785
Mailing Address - Country:US
Mailing Address - Phone:734-728-8800
Mailing Address - Fax:
Practice Address - Street 1:35102 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1785
Practice Address - Country:US
Practice Address - Phone:734-728-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010189101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4887078Medicaid