Provider Demographics
NPI:1831832039
Name:POTOCKI PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:POTOCKI PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-361-1512
Mailing Address - Street 1:12365 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-8000
Mailing Address - Country:US
Mailing Address - Phone:517-764-6283
Mailing Address - Fax:
Practice Address - Street 1:12365 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-8000
Practice Address - Country:US
Practice Address - Phone:517-764-6283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental