Provider Demographics
NPI:1497985659
Name:DECAROLIS, GIANNI SANTE (DMD)
Entity Type:Individual
Prefix:
First Name:GIANNI
Middle Name:SANTE
Last Name:DECAROLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23400 MICHIGAN AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1924
Mailing Address - Country:US
Mailing Address - Phone:313-565-9118
Mailing Address - Fax:313-565-2672
Practice Address - Street 1:23400 MICHIGAN AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1924
Practice Address - Country:US
Practice Address - Phone:313-565-9118
Practice Address - Fax:313-565-2672
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186811223E0200X
MI29010200901223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics