Healthcare Provider Details

I. General information

NPI: 1821047879
Provider Name (Legal Business Name): MIDWESTERN PERIODONTIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 SCHAEFER RD
DEARBORN MI
48126-3249
US

IV. Provider business mailing address

5050 SCHAEFER RD
DEARBORN MI
48126-3249
US

V. Phone/Fax

Practice location:
  • Phone: 313-582-8150
  • Fax: 313-582-6015
Mailing address:
  • Phone: 313-582-8150
  • Fax: 313-582-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberN/A
License Number State

VIII. Authorized Official

Name: JOHN MORGAN JR.
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 313-582-8150