Healthcare Provider Details

I. General information

NPI: 1477621290
Provider Name (Legal Business Name): ROY D MCANNELLY DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W BIG BEAVER RD SUITE 215
BLOOMFIELD HILLS MI
48304
US

IV. Provider business mailing address

50 W BIG BEAVER RD SUITE 215
BLOOMFIELD HILLS MI
48304
US

V. Phone/Fax

Practice location:
  • Phone: 248-647-0696
  • Fax:
Mailing address:
  • Phone: 248-647-0696
  • Fax: 248-647-3257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901011253 0935920
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901011253 0936712
License Number StateMI

VIII. Authorized Official

Name: DR. ROY D MCANNALLY
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 248-647-0696