Provider Demographics
NPI:1568638609
Name:STUART L DAVIDSON D D S P C
Entity Type:Organization
Organization Name:STUART L DAVIDSON D D S P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:D D S
Authorized Official - Phone:586-573-0030
Mailing Address - Street 1:11270 E 13 MILE RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2599
Mailing Address - Country:US
Mailing Address - Phone:586-573-0030
Mailing Address - Fax:586-573-0072
Practice Address - Street 1:11270 E 13 MILE RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2599
Practice Address - Country:US
Practice Address - Phone:586-573-0030
Practice Address - Fax:586-573-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010077901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5506572Medicare PIN
MIT71125Medicare UPIN