MEDICARE: COBBLESTONE RIDGE DENTISTRY

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	122300000X	Dentist

General Provider Information

NPI Number	:	1982311767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COBBLESTONE RIDGE DENTISTRY

Provider Business Mailing Address
First Line	:	16800 24 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-2990
Country	:	US
Telephone Number	:	586-612-8472
Fax Number	:

Provider Business Practice Location Address
First Line	:	16800 24 MILE RD STE 5
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-2990
Country	:	US
Telephone Number	:	586-781-2757
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. JEFFREY TENO
Credential	:	DDS
Telephone Number	:	586-781-2757

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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