Provider Demographics
NPI:1689782849
Name:UNIVERSITY DENTAL ASSOC., PC
Entity Type:Organization
Organization Name:UNIVERSITY DENTAL ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GIBBS
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-652-9116
Mailing Address - Street 1:435 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1933
Mailing Address - Country:US
Mailing Address - Phone:248-652-9116
Mailing Address - Fax:248-652-3136
Practice Address - Street 1:435 PINE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1933
Practice Address - Country:US
Practice Address - Phone:248-652-9116
Practice Address - Fax:248-652-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty