MEDICARE: 42 NORTH DENTAL CARE OF MICHIGAN, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1679213573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	42 NORTH DENTAL CARE OF MICHIGAN, PLLC

Provider Business Mailing Address
First Line	:	21635 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48091-2788
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21635 RYAN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48091-2788
Country	:	US
Telephone Number	:	586-757-7540
Fax Number	:

Authorized Official
Title or Position	:	CHIEF CLINICAL OFFICER
Name	:	MICHAEL ANGELO SCIALABBA
Credential	:
Telephone Number	:	561-512-2709

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	03/30/2022

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