1174557482 NPI number — RENAISSANCE ENDODONTICS, PLLC

Table of content: (NPI 1174557482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174557482 NPI number — RENAISSANCE ENDODONTICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE ENDODONTICS, PLLC
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:
1174557482
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:
PO BOX 87068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48187-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-395-9800
Provider Business Mailing Address Fax Number:
248-395-9778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23077 GREENFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 285
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-395-9800
Provider Business Practice Location Address Fax Number:
248-395-9778
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
YAKOV
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
248-395-9800

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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