Provider Demographics
NPI:1679721294
Name:DEVELOPMENTAL DENTISTRY, PLLC
Entity Type:Organization
Organization Name:DEVELOPMENTAL DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-576-2538
Mailing Address - Street 1:79 W ALEXANDRINE ST
Mailing Address - Street 2:3RD. FLOOR
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2015
Mailing Address - Country:US
Mailing Address - Phone:313-576-2538
Mailing Address - Fax:313-576-2534
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:3RD. FLOOR
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-576-2538
Practice Address - Fax:313-576-2534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty