Healthcare Provider Details

I. General information

NPI: 1306014816
Provider Name (Legal Business Name): ANN ARBOR DENTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E EISENHOWER PKWY SUITE 200
ANN ARBOR MI
48108-5205
US

IV. Provider business mailing address

3100 E EISENHOWER PKWY SUITE 200
ANN ARBOR MI
48108-5205
US

V. Phone/Fax

Practice location:
  • Phone: 734-971-3368
  • Fax: 734-971-3979
Mailing address:
  • Phone: 734-971-3368
  • Fax: 734-971-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901010113
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901018096
License Number StateMI

VIII. Authorized Official

Name: DR. JAMES W CLARK
Title or Position: DENTIST
Credential: D.D.S., M.S.
Phone: 734-971-3368