Provider Demographics
NPI:1588839013
Name:HAMTRAMCK DENTAL CENTER
Entity Type:Organization
Organization Name:HAMTRAMCK DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:THAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:STIPHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-369-3385
Mailing Address - Street 1:3120 CARPENTER ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-9802
Mailing Address - Country:US
Mailing Address - Phone:313-369-3385
Mailing Address - Fax:313-368-0275
Practice Address - Street 1:3120 CARPENTER ST
Practice Address - Street 2:SUITE 109
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-9802
Practice Address - Country:US
Practice Address - Phone:313-369-3385
Practice Address - Fax:313-368-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0174781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124275708Medicaid