Provider Demographics
NPI:1457476053
Name:SENIORCARE MOBILE DENTISTRY
Entity Type:Organization
Organization Name:SENIORCARE MOBILE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JERGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-445-2320
Mailing Address - Street 1:22540 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2941
Mailing Address - Country:US
Mailing Address - Phone:586-445-1802
Mailing Address - Fax:
Practice Address - Street 1:22540 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2941
Practice Address - Country:US
Practice Address - Phone:586-445-1802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013471314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4068883Medicaid