Provider Demographics
NPI:1902203227
Name:MICHIGAN PRIVATE DENTAL GROUP
Entity Type:Organization
Organization Name:MICHIGAN PRIVATE DENTAL GROUP
Other - Org Name:STONERIDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BIELKIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-771-3440
Mailing Address - Street 1:27731 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1309
Mailing Address - Country:US
Mailing Address - Phone:586-771-6440
Mailing Address - Fax:586-771-8877
Practice Address - Street 1:27731 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1309
Practice Address - Country:US
Practice Address - Phone:586-771-6440
Practice Address - Fax:586-771-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI158101223G0001X
MI192411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty