Provider Demographics
NPI:1881859239
Name:WOLVERINE COSMETIC DENTAL L.L.C
Entity type:Organization
Organization Name:WOLVERINE COSMETIC DENTAL L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-395-4700
Mailing Address - Street 1:17070 W 12 MILE RD
Mailing Address - Street 2:C
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2116
Mailing Address - Country:US
Mailing Address - Phone:248-395-4700
Mailing Address - Fax:248-395-4703
Practice Address - Street 1:17070 W. 12 MILE RD
Practice Address - Street 2:C
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2116
Practice Address - Country:US
Practice Address - Phone:248-395-4700
Practice Address - Fax:248-395-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019508122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497949945Medicaid
MI1437252467Medicaid