Provider Demographics
NPI:1558671370
Name:ADVANCED DENTAL IMAGING OF MICHIGAN, PLLC
Entity Type:Organization
Organization Name:ADVANCED DENTAL IMAGING OF MICHIGAN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:T
Authorized Official - Last Name:VANDEVELDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-977-1012
Mailing Address - Street 1:10 W SQUARE LAKE RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0465
Mailing Address - Country:US
Mailing Address - Phone:248-977-1012
Mailing Address - Fax:
Practice Address - Street 1:10 W SQUARE LAKE RD
Practice Address - Street 2:SUITE 305
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0465
Practice Address - Country:US
Practice Address - Phone:248-977-1012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901014174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty