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
State | License ID | Taxonomies |
---|---|---|
122300000X, 1223E0200X, 1223P0106X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0008X, 1223X0400X | ||
MI | 2901016040 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |
No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
No | 1223E0200X | Dental Providers | Dentist | Endodontics | Group - Multi-Specialty |
No | 1223P0106X | Dental Providers | Dentist | Oral and Maxillofacial Pathology | Group - Multi-Specialty |
No | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Multi-Specialty |
No | 1223P0300X | Dental Providers | Dentist | Periodontics | Group - Multi-Specialty |
No | 1223P0700X | Dental Providers | Dentist | Prosthodontics | Group - Multi-Specialty |
No | 1223S0112X | Dental Providers | Dentist | Oral and Maxillofacial Surgery | Group - Multi-Specialty |
No | 1223X0008X | Dental Providers | Dentist | Oral and Maxillofacial Radiology | Group - Multi-Specialty |
No | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 970H110770 | Other | BCBS OF MI ORALSURGERY |
MI | XX19411 | Other | HEALTH PLUS OF MI |
MI | 1006664 | Other | MCLAREN ADVANTAGE |
OH | 2667609 | Medicaid | |
MI | 43-20001 | Other | PHP OF MI |
MI | 43-28004 | Other | PHP OF MI |
MI | 4504346 | Medicaid | |
MI | 190H110980 | Other | BCBS OF MI MEDSURG # |
MI | 025748 | Other | MIDWEST HEALTH |
MI | 1476671 | Other | UNITED CONCORDIA |
MI | 4504373 | Medicaid | |
MI | 88054 | Other | DELTA DENTAL OF MI - GENL |
MI | D800363 | Other | BCBS OF MI GENLDENTIST |
MI | QMXPR0014549 | Other | MOLINA HEALTHCARE |
MI | 43-28004 | Other | PHP OF MI |
MI | 4504373 | Medicaid |