1265682900 NPI number — OLDE ORCHARD PEDIATRIC DENTISTRY

Table of content: (NPI 1265682900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265682900 NPI number — OLDE ORCHARD PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLDE ORCHARD PEDIATRIC DENTISTRY
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:
SUSAN H. CARRON, D.D.S., M.S.
Provider Other Organization Name Type Code:
3
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:
1265682900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40105 GRAND RIVER AVE STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-2170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-478-3232
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40105 GRAND RIVER AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48375-2170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-478-3232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
DAPHNE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT OFFICE MANAGER
Authorized Official Telephone Number:
248-478-3232

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  2901011539 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2669122 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2823071 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com