Provider Demographics
NPI:1598497653
Name:WAVE DENTAL SPECIALISTS DETROIT
Entity Type:Organization
Organization Name:WAVE DENTAL SPECIALISTS DETROIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBO LEADER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-372-7358
Mailing Address - Street 1:2112 PERRY PLACE LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-8700
Mailing Address - Country:US
Mailing Address - Phone:678-372-7358
Mailing Address - Fax:
Practice Address - Street 1:27283 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1804
Practice Address - Country:US
Practice Address - Phone:313-380-6323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty