Provider Demographics
NPI:1770507451
Name:KELLY PLAZA DENTAL CT. PC
Entity Type:Organization
Organization Name:KELLY PLAZA DENTAL CT. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PURIFOY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-839-8200
Mailing Address - Street 1:12434 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1518
Mailing Address - Country:US
Mailing Address - Phone:313-839-8200
Mailing Address - Fax:313-839-2772
Practice Address - Street 1:12434 KELLY RD.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224
Practice Address - Country:US
Practice Address - Phone:313-839-8200
Practice Address - Fax:313-839-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15938541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty