Healthcare Provider Details

I. General information

NPI: 1144312760
Provider Name (Legal Business Name): EASTSIDE PERIODONTAL ASSOC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25523 VAN DYKE AVE
CENTER LINE MI
48015-1824
US

IV. Provider business mailing address

25523 VAN DYKE AVE
CENTER LINE MI
48015-1824
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-5454
  • Fax: 586-757-4147
Mailing address:
  • Phone: 586-757-5454
  • Fax: 586-757-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberB18275
License Number StateMI

VIII. Authorized Official

Name: MRS. JENNIFER LYNN WISE
Title or Position: OFFICE MANAGER
Credential:
Phone: 586-757-5454