Provider Demographics
NPI:1497347686
Name:RENEWAL FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:RENEWAL FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SABAH
Authorized Official - Middle Name:LILLIAN
Authorized Official - Last Name:GAGNON-SALEEBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-213-2505
Mailing Address - Street 1:600 RIDGEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1221
Mailing Address - Country:US
Mailing Address - Phone:313-213-2505
Mailing Address - Fax:
Practice Address - Street 1:22190 GARRISON ST STE 201
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2235
Practice Address - Country:US
Practice Address - Phone:313-277-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1982087953OtherOWNER OF PRACTICE