Provider Demographics
NPI:1689224818
Name:WATERFORD KIDS DENTAL CLUB, PLLC
Entity Type:Organization
Organization Name:WATERFORD KIDS DENTAL CLUB, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECA
Authorized Official - Middle Name:
Authorized Official - Last Name:URQUIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-909-2132
Mailing Address - Street 1:4220 SURREY CROSS
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1669
Mailing Address - Country:US
Mailing Address - Phone:248-909-2132
Mailing Address - Fax:
Practice Address - Street 1:3801 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3017
Practice Address - Country:US
Practice Address - Phone:248-909-2132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty