MEDICARE: MIDWESTERN DENTAL OF DETROIT

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	1223G0001X	General Practice Dentistry	N/A

General Provider Information

NPI Number	:	1760431936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWESTERN DENTAL OF DETROIT

Provider Business Mailing Address
First Line	:	5050 SCHAEFER RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-3249
Country	:	US
Telephone Number	:	313-582-8150
Fax Number	:	313-582-6015

Provider Business Practice Location Address
First Line	:	1415 TRUMBULL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48216-1368
Country	:	US
Telephone Number	:	313-963-2222
Fax Number	:	313-963-3665

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	JOHN MORGAN JR.
Credential	:
Telephone Number	:	313-582-8150

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/22/2020

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