Provider Demographics
NPI:1922272152
Name:PAUL DENTAL GROUP, PC
Entity Type:Organization
Organization Name:PAUL DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AGYEKUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-839-7900
Mailing Address - Street 1:14521 E 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-2446
Mailing Address - Country:US
Mailing Address - Phone:313-839-7999
Mailing Address - Fax:313-839-0639
Practice Address - Street 1:14521 E 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2446
Practice Address - Country:US
Practice Address - Phone:313-839-7999
Practice Address - Fax:313-839-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3106916Medicaid