Provider Demographics
NPI:1932541455
Name:PERIODONTAL SPECIALISTS OF FLINT PC
Entity Type:Organization
Organization Name:PERIODONTAL SPECIALISTS OF FLINT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUHEIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:810-695-6444
Mailing Address - Street 1:8185 HOLLY RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2444
Mailing Address - Country:US
Mailing Address - Phone:810-695-6444
Mailing Address - Fax:
Practice Address - Street 1:4252 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2953
Practice Address - Country:US
Practice Address - Phone:810-733-1890
Practice Address - Fax:810-733-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty