Provider Demographics
NPI:1508974387
Name:HAMTRAMCK DENTAL CENTER
Entity Type:Organization
Organization Name:HAMTRAMCK DENTAL CENTER
Other - Org Name:WILBERT PURIFOY OWNER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PURIFOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-972-4700
Mailing Address - Street 1:9541 JOS CAMPALL
Mailing Address - Street 2:
Mailing Address - City:HAMTRACK
Mailing Address - State:MI
Mailing Address - Zip Code:48212
Mailing Address - Country:US
Mailing Address - Phone:313-972-4700
Mailing Address - Fax:313-972-1105
Practice Address - Street 1:9541 JOS CAMPALL
Practice Address - Street 2:HAMTRAMCK DENTAL CENTER
Practice Address - City:HAMTRACK
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-972-4700
Practice Address - Fax:313-972-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10915122300000X
NY13106122300000X
MI17875122300000X
MI174101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
77875OtherAHMED ALLAN
10915OtherPURIFOY
17470OtherFRANK HARRIS
13106OtherPAUL ONEILL
MI2744290Medicaid