Provider Demographics
NPI:1881642122
Name:MIDWESTERN DENTAL OF DEARBORN
Entity Type:Organization
Organization Name:MIDWESTERN DENTAL OF DEARBORN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-582-8150
Mailing Address - Street 1:5050 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3249
Mailing Address - Country:US
Mailing Address - Phone:313-582-8150
Mailing Address - Fax:313-582-6015
Practice Address - Street 1:5050 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3249
Practice Address - Country:US
Practice Address - Phone:313-582-8150
Practice Address - Fax:313-582-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty