Provider Demographics
NPI:1710250071
Name:PALM FAMILY DENTAL DDS PC
Entity Type:Organization
Organization Name:PALM FAMILY DENTAL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-398-6046
Mailing Address - Street 1:26789 WOODWARD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1335
Mailing Address - Country:US
Mailing Address - Phone:248-398-6046
Mailing Address - Fax:248-398-6850
Practice Address - Street 1:26789 WOODWARD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1335
Practice Address - Country:US
Practice Address - Phone:248-398-6046
Practice Address - Fax:248-398-6850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty