Provider Demographics
NPI:1629371182
Name:WEST BLOMMFIELD DENTAL AND ASSOCIATES PLLC
Entity Type:Organization
Organization Name:WEST BLOMMFIELD DENTAL AND ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-851-5650
Mailing Address - Street 1:6900 ORCHARD LAKE RD
Mailing Address - Street 2:211
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3405
Mailing Address - Country:US
Mailing Address - Phone:248-851-5650
Mailing Address - Fax:248-851-5663
Practice Address - Street 1:6900 ORCHARD LAKE RD
Practice Address - Street 2:211
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3405
Practice Address - Country:US
Practice Address - Phone:248-851-5650
Practice Address - Fax:248-851-5663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI017174122300000X
MI2902011884124Q00000X
124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty