Healthcare Provider Details

I. General information

NPI: 1588859664
Provider Name (Legal Business Name): MISTI SPRING PRATT D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST 3RD FLOOR
DETROIT MI
48201-2015
US

IV. Provider business mailing address

7206 FIELDS DR
INDIANAPOLIS IN
46239-7756
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-2895
  • Fax:
Mailing address:
  • Phone: 317-698-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011063A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901020651
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: