Provider Demographics
NPI:1699015339
Name:PROFESSIONAL PERIODONTICS
Entity Type:Organization
Organization Name:PROFESSIONAL PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MERAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-751-0070
Mailing Address - Street 1:30101 HOOVER RD STE A
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-6572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30101 HOOVER RD STE A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6572
Practice Address - Country:US
Practice Address - Phone:586-751-0070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-17
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017594261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental