Provider Demographics
NPI:1659875144
Name:SOUTHFIELD GUM DOCS, LLC
Entity Type:Organization
Organization Name:SOUTHFIELD GUM DOCS, LLC
Other - Org Name:MICHIGAN GUM DOCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:UNPRICED
Authorized Official - Last Name:KRIVICHKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-327-1919
Mailing Address - Street 1:18860 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2666
Mailing Address - Country:US
Mailing Address - Phone:248-327-1919
Mailing Address - Fax:248-552-0992
Practice Address - Street 1:18860 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2666
Practice Address - Country:US
Practice Address - Phone:248-327-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI210981223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty