Provider Demographics
NPI:1497900302
Name:CENTERLINE DENTURE CLINIC
Entity Type:Organization
Organization Name:CENTERLINE DENTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-756-5880
Mailing Address - Street 1:24625 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-2303
Mailing Address - Country:US
Mailing Address - Phone:586-756-5880
Mailing Address - Fax:
Practice Address - Street 1:24625 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-2303
Practice Address - Country:US
Practice Address - Phone:586-756-5880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4963261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental