Provider Demographics
NPI:1568852382
Name:CLARKSTON PEDIATRIC DENTISTRY PLC
Entity Type:Organization
Organization Name:CLARKSTON PEDIATRIC DENTISTRY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-795-5131
Mailing Address - Street 1:6401 CITATION DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2992
Mailing Address - Country:US
Mailing Address - Phone:248-625-3603
Mailing Address - Fax:248-625-7164
Practice Address - Street 1:6401 CITATION DR
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2992
Practice Address - Country:US
Practice Address - Phone:248-625-3603
Practice Address - Fax:248-625-7164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-01
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021075261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental