Provider Demographics
NPI:1538509633
Name:SUPER DENTAL OF LIVERNOIS AVE, PC
Entity Type:Organization
Organization Name:SUPER DENTAL OF LIVERNOIS AVE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:2484181021
Authorized Official - Phone:248-418-1021
Mailing Address - Street 1:15510 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1343
Mailing Address - Country:US
Mailing Address - Phone:313-863-2800
Mailing Address - Fax:
Practice Address - Street 1:15510 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1343
Practice Address - Country:US
Practice Address - Phone:313-863-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty