Healthcare Provider Details

I. General information

NPI: 1407698541
Provider Name (Legal Business Name): DENTISTRYONE OF MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W CONGRESS ST FL 2
DETROIT MI
48226-3289
US

IV. Provider business mailing address

20 HIGHLAND AVE
METUCHEN NJ
08840-1949
US

V. Phone/Fax

Practice location:
  • Phone: 877-712-7875
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DEREK WEIGAND
Title or Position: OWNER
Credential:
Phone: 877-712-7875