Provider Demographics
NPI:1528370434
Name:REGENTS OF THE UNIVERSITY OF MICHIGAN DENTAL FACULTY ASSOCIATES
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MICHIGAN DENTAL FACULTY ASSOCIATES
Other - Org Name:DENTAL FACULTY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN SCHOOL OF DENTISTRY
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLVERINI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:734-763-3311
Mailing Address - Street 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-763-3311
Mailing Address - Fax:764-763-5142
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-763-3311
Practice Address - Fax:764-763-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016970204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty