Healthcare Provider Details

I. General information

NPI: 1174044846
Provider Name (Legal Business Name): MICHIGAN DENTAL ASSOCIATES II PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27281 W WARREN ST
DEARBORN HEIGHTS MI
48127-1804
US

IV. Provider business mailing address

999 PEACHTREE ST NE STE 800
ATLANTA GA
30309-4425
US

V. Phone/Fax

Practice location:
  • Phone: 313-274-4040
  • Fax:
Mailing address:
  • Phone: 678-372-7358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901013819
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARTHA J HARP
Title or Position: DIRECTOR OF INSURANCE OPERATIONS
Credential:
Phone: 678-372-7358