MEDICARE: TRU DENTAL MICHIGAN PC

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

General Provider Information

NPI Number	:	1871187195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRU DENTAL MICHIGAN PC

Provider Business Mailing Address
First Line	:	4925 S TELEGRAPH RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2027
Country	:	US
Telephone Number	:	313-291-4970
Fax Number	:	313-291-4970

Provider Business Practice Location Address
First Line	:	4925 S TELEGRAPH RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2027
Country	:	US
Telephone Number	:	313-291-4970
Fax Number	:	313-291-4970

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CELIA HAYES
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	02/26/2021
Last Update Date	:	02/26/2021

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