Healthcare Provider Details

I. General information

NPI: 1194962753
Provider Name (Legal Business Name): MICHIGAN IMPLANTS & PERIODONTICS INSTITUTE, P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 CARPENTER RD SUITE 2NE
ANN ARBOR MI
48108-1186
US

IV. Provider business mailing address

2755 CARPENTER RD SUITE 2NE
ANN ARBOR MI
48108-1186
US

V. Phone/Fax

Practice location:
  • Phone: 734-975-1743
  • Fax:
Mailing address:
  • Phone: 734-975-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901018946
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901019093
License Number StateMI

VIII. Authorized Official

Name: DR. KELLY MISCH
Title or Position: MANAGER
Credential: D.D.S., M.S.
Phone: 734-975-1743