Healthcare Provider Details

I. General information

NPI: 1174602049
Provider Name (Legal Business Name): JACK SCHWARCZ D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/18/2015
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 Number13928
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: