Provider Demographics
NPI:1770164980
Name:TRU DENTAL MICHIGAN PC
Entity type:Organization
Organization Name:TRU DENTAL MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:155 ROWE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1645
Mailing Address - Country:US
Mailing Address - Phone:517-647-6205
Mailing Address - Fax:517-647-6205
Practice Address - Street 1:155 ROWE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1645
Practice Address - Country:US
Practice Address - Phone:517-647-6205
Practice Address - Fax:517-647-6205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRU DENTAL MICHIGAN PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty