1497878375 NPI number — WB DENTAL CENTERS P.C.

Table of content: (NPI 1497878375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497878375 NPI number — WB DENTAL CENTERS P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WB DENTAL CENTERS 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:
WEST BLOOMFIELD DENTAL CENTER P.C.
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:
1497878375
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45055 COBBLESTONE
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:
48377-1395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-669-6608
Provider Business Mailing Address Fax Number:
248-681-3610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3435 ORCHARD LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEEGO HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48320-1315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-681-4660
Provider Business Practice Location Address Fax Number:
248-681-3610
Provider Enumeration Date:
04/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-669-6608

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901018302 , 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)





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