Healthcare Provider Details

I. General information

NPI: 1457188955
Provider Name (Legal Business Name): PRO DENTAL MI 1 PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21427 GRAND RIVER AVE STE 100
DETROIT MI
48219-3897
US

IV. Provider business mailing address

10 WOODBRIDGE CENTER DR STE 520
WOODBRIDGE NJ
07095-1152
US

V. Phone/Fax

Practice location:
  • Phone: 313-412-2100
  • Fax: 313-766-7734
Mailing address:
  • Phone: 732-914-1422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. SIMONE WILSON-ADELEKE
Title or Position: DIRECTOR OF CREDENTIALING
Credential: MPA-PPA
Phone: 732-914-3991