Provider Demographics
NPI:1689068876
Name:ST APOLLONIA DENTTAL
Entity Type:Organization
Organization Name:ST APOLLONIA DENTTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-323-1320
Mailing Address - Street 1:43158 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1723
Mailing Address - Country:US
Mailing Address - Phone:586-323-1320
Mailing Address - Fax:586-323-1530
Practice Address - Street 1:43158 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1723
Practice Address - Country:US
Practice Address - Phone:586-323-1320
Practice Address - Fax:586-323-1530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901013190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty