Provider Demographics
NPI:1679681126
Name:SKELLY & ZAGER DDS PC
Entity Type:Organization
Organization Name:SKELLY & ZAGER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:ZAGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-565-3131
Mailing Address - Street 1:24718 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-565-7103
Mailing Address - Fax:313-565-7103
Practice Address - Street 1:24718 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-565-3131
Practice Address - Fax:313-565-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ801010OtherBLUE CROSS BLUE SHEILD
MI799854OtherUNITED CONCORDIA