Healthcare Provider Details

I. General information

NPI: 1598497653
Provider Name (Legal Business Name): WAVE DENTAL SPECIALISTS DETROIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27283 W WARREN ST
DEARBORN HEIGHTS MI
48127-1804
US

IV. Provider business mailing address

2112 PERRY PLACE LN
MONROE GA
30656-8700
US

V. Phone/Fax

Practice location:
  • Phone: 313-380-6323
  • Fax:
Mailing address:
  • Phone: 678-372-7358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTHA HARP
Title or Position: CBO LEADER
Credential:
Phone: 678-372-7358