Healthcare Provider Details

I. General information

NPI: 1376908392
Provider Name (Legal Business Name): MICHIGAN DENTAL SLEEP CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4279 W VIENNA RD
CLIO MI
48420-9440
US

IV. Provider business mailing address

4279 W VIENNA RD
CLIO MI
48420-9440
US

V. Phone/Fax

Practice location:
  • Phone: 810-659-1721
  • Fax: 810-659-0897
Mailing address:
  • Phone: 810-659-1721
  • Fax: 810-659-0897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CHAD M WITKOW
Title or Position: PRESIDENT
Credential: DDS
Phone: 810-659-1721