Provider Demographics
NPI:1932279882
Name:REGENTS OF THE UNIVERSITY OF MICHIGAN DENTAL FACULTY ASSOCIATES
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MICHIGAN DENTAL FACULTY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN, UNIV OF MI SCHOOL OF DENTISTR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLVERINI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-764-9185
Mailing Address - Street 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:734-764-9185
Mailing Address - Fax:734-647-8090
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-764-3155
Practice Address - Fax:734-615-4784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223E0200X, 1223P0106X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0008X, 1223X0400X
MI29010160401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970H110770OtherBCBS OF MI ORALSURGERY
MIXX19411OtherHEALTH PLUS OF MI
MI1006664OtherMCLAREN ADVANTAGE
OH2667609Medicaid
MI43-20001OtherPHP OF MI
MI43-28004OtherPHP OF MI
MI4504346Medicaid
MI190H110980OtherBCBS OF MI MEDSURG #
MI025748OtherMIDWEST HEALTH
MI1476671OtherUNITED CONCORDIA
MI4504373Medicaid
MI88054OtherDELTA DENTAL OF MI - GENL
MID800363OtherBCBS OF MI GENLDENTIST
MIQMXPR0014549OtherMOLINA HEALTHCARE
MI43-28004OtherPHP OF MI
MI4504373Medicaid