Provider Demographics
NPI:1710495874
Name:KID'S FIRST PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:KID'S FIRST PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT/FRONT DESK
Authorized Official - Prefix:
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-386-0570
Mailing Address - Street 1:3778 DIX HWY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3807
Mailing Address - Country:US
Mailing Address - Phone:313-386-0570
Mailing Address - Fax:
Practice Address - Street 1:3778 DIX HWY
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3807
Practice Address - Country:US
Practice Address - Phone:313-386-0570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010220621223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVS0034738Medicaid