1336231497 NPI number — DOWNRIVER DENTAL ASSOCIATES P.C.

Table of content: (NPI 1336231497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336231497 NPI number — DOWNRIVER DENTAL ASSOCIATES P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOWNRIVER DENTAL ASSOCIATES P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336231497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3830 FORT ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-383-6800
Provider Business Mailing Address Fax Number:
313-383-1026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3830 FORT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-383-6800
Provider Business Practice Location Address Fax Number:
313-383-1026
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRUMET
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
313-383-6800

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D803850 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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