Healthcare Provider Details

I. General information

NPI: 1174075816
Provider Name (Legal Business Name): DR. PRATIKSHA AGRAWAL DENTAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 TELEGRAPH ROAD SUITE 104
BLOOLFIELD HILLS MI
48302
US

IV. Provider business mailing address

1468 DEVON LANE
TROY MI
48084
US

V. Phone/Fax

Practice location:
  • Phone: 248-292-0188
  • Fax:
Mailing address:
  • Phone: 312-208-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: PRATIKSHA AGRAWAL
Title or Position: ASSOCIATE DENTIST
Credential:
Phone: 312-208-5566