Provider Demographics
NPI:1770666364
Name:UNIVERSITY OF DETROIT MERCY SCHOOL OF DENTISTRY
Entity Type:Organization
Organization Name:UNIVERSITY OF DETROIT MERCY SCHOOL OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DEAN CLINIC ADMINISTRATIO
Authorized Official - Prefix:DR
Authorized Official - First Name:MERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:AKSU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-494-6750
Mailing Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-2576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI014855122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4839553Medicaid
MI3473192Medicaid