Provider Demographics
NPI:1932292216
Name:MICHAEL J. DEPORRE, D.D.S., P.C.
Entity Type:Organization
Organization Name:MICHAEL J. DEPORRE, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEPORRE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-656-2244
Mailing Address - Street 1:2490 WALTON BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1484
Mailing Address - Country:US
Mailing Address - Phone:248-656-2244
Mailing Address - Fax:248-656-0225
Practice Address - Street 1:2490 WALTON BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1484
Practice Address - Country:US
Practice Address - Phone:248-656-2244
Practice Address - Fax:248-656-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI138661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4658155Medicaid
MIU27874Medicare UPIN