Provider Demographics
NPI:1639569684
Name:DIVINE FAMILY DENISTRY
Entity Type:Organization
Organization Name:DIVINE FAMILY DENISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDEL-HAMEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-445-2990
Mailing Address - Street 1:27845 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4848
Mailing Address - Country:US
Mailing Address - Phone:586-445-2990
Mailing Address - Fax:
Practice Address - Street 1:27845 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4848
Practice Address - Country:US
Practice Address - Phone:586-445-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty