Provider Demographics
NPI:1619026085
Name:KENNEDY DENTAL CENTER OF MICHIGAN, P.C.
Entity Type:Organization
Organization Name:KENNEDY DENTAL CENTER OF MICHIGAN, P.C.
Other - Org Name:KENNEDY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRZA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAIG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-755-5700
Mailing Address - Street 1:23800 ORCHARD LAKE RD
Mailing Address - Street 2:STE. 106
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2560
Mailing Address - Country:US
Mailing Address - Phone:248-755-5700
Mailing Address - Fax:248-471-7383
Practice Address - Street 1:1193 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2450
Practice Address - Country:US
Practice Address - Phone:313-388-1800
Practice Address - Fax:313-388-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010178491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty