Provider Demographics
NPI:1619533171
Name:LIVERNOIS DENTAL CARE PLLC
Entity Type:Organization
Organization Name:LIVERNOIS DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHISELOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-977-0255
Mailing Address - Street 1:17170 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3028
Mailing Address - Country:US
Mailing Address - Phone:313-340-9709
Mailing Address - Fax:313-397-9245
Practice Address - Street 1:17170 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3028
Practice Address - Country:US
Practice Address - Phone:313-340-9709
Practice Address - Fax:313-397-9245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental