Healthcare Provider Details

I. General information

NPI: 1760597066
Provider Name (Legal Business Name): PERIODONTIC AND DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/22/2020
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: 734-975-1754
Mailing address:
  • Phone: 734-975-1743
  • Fax: 734-975-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number2901016548
License Number StateMI

VIII. Authorized Official

Name: NIVEDITA S KUMAR
Title or Position: PERIODONTIST
Credential: B.D.S., M.S.
Phone: 734-975-1743