Provider Demographics
NPI:1487829743
Name:ORCHARD-TWELVE DENTAL CENTER PC
Entity Type:Organization
Organization Name:ORCHARD-TWELVE DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, RDA
Authorized Official - Phone:248-865-0065
Mailing Address - Street 1:27970 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3767
Mailing Address - Country:US
Mailing Address - Phone:248-865-0065
Mailing Address - Fax:248-865-7898
Practice Address - Street 1:27970 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3767
Practice Address - Country:US
Practice Address - Phone:248-865-0065
Practice Address - Fax:248-865-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty