Healthcare Provider Details

I. General information

NPI: 1932946464
Provider Name (Legal Business Name): EASTSIDE IMPLANTS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25523 VAN DYKE AVENUE
CENTER LINE MI
48015
US

IV. Provider business mailing address

25523 VAN DYKE AVENUE
CENTER LINE MI
48015
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-5454
  • Fax: 586-757-4147
Mailing address:
  • Phone: 734-975-1743
  • Fax: 734-975-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: KELLY MISCH
Title or Position: OWNER/PERIODONTIST
Credential: D.D.S., M.S.
Phone: 734-975-1743