1417713389 NPI number — ST CLAIRE SHORES FAMILY DENTAL PLLC

Table of content: (NPI 1417713389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417713389 NPI number — ST CLAIRE SHORES FAMILY DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CLAIRE SHORES FAMILY DENTAL 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:
CLAIRPOINTE FAMILY DENTAL
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:
1417713389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23995 GREATER MACK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48080-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-775-1040
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23995 GREATER MACK AVENUE, STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-928-2150
Provider Business Practice Location Address Fax Number:
313-928-3616
Provider Enumeration Date:
02/27/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
AJLUNI
Authorized Official First Name:
REMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-515-0746

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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