Provider Demographics
NPI:1669209938
Name:PRO DENTAL MI 1 PC
Entity type:Organization
Organization Name:PRO DENTAL MI 1 PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON-ADELEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MPA-PPA
Authorized Official - Phone:732-731-8398
Mailing Address - Street 1:10 WOODBRIDGE CENTER DR STE 520
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1152
Mailing Address - Country:US
Mailing Address - Phone:732-731-8398
Mailing Address - Fax:
Practice Address - Street 1:16201 FORD RD STE 115
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2876
Practice Address - Country:US
Practice Address - Phone:313-451-8304
Practice Address - Fax:313-789-7993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty