Provider Demographics
NPI:1932319746
Name:JEWELL FAMILY DENTAL
Entity Type:Organization
Organization Name:JEWELL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-535-7770
Mailing Address - Street 1:19135 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1704
Mailing Address - Country:US
Mailing Address - Phone:313-535-7770
Mailing Address - Fax:
Practice Address - Street 1:19135 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1704
Practice Address - Country:US
Practice Address - Phone:313-535-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI173361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty