Provider Demographics
NPI:1184076697
Name:CANTON PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:CANTON PEDIATRIC DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCHEFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-335-7270
Mailing Address - Street 1:1657 N CANTON CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2948
Mailing Address - Country:US
Mailing Address - Phone:734-335-7270
Mailing Address - Fax:734-667-4648
Practice Address - Street 1:1657 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2948
Practice Address - Country:US
Practice Address - Phone:734-335-7270
Practice Address - Fax:734-667-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty