Provider Demographics
NPI:1760263248
Name:FOREVER YOUNG DENTISTRY BAYSIDE PC
Entity Type:Organization
Organization Name:FOREVER YOUNG DENTISTRY BAYSIDE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-795-5678
Mailing Address - Street 1:39242 DEQUINDRE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-1767
Mailing Address - Country:US
Mailing Address - Phone:586-795-5678
Mailing Address - Fax:
Practice Address - Street 1:36555 26 MILE RD STE 3900
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MI
Practice Address - Zip Code:48048-3190
Practice Address - Country:US
Practice Address - Phone:586-277-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty