Provider Demographics
NPI:1467616292
Name:VERNOR DENTAL CARE
Entity Type:Organization
Organization Name:VERNOR DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-843-4003
Mailing Address - Street 1:8044 W VERNOR HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209
Mailing Address - Country:US
Mailing Address - Phone:313-843-4003
Mailing Address - Fax:313-842-9311
Practice Address - Street 1:8044 W VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209
Practice Address - Country:US
Practice Address - Phone:313-843-4003
Practice Address - Fax:313-842-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0184291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4609947Medicaid
MI4873920Medicaid
MI4689868Medicaid