Healthcare Provider Details

I. General information

NPI: 1912035817
Provider Name (Legal Business Name): SUZANNE PASTERNAK D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST STE 2F
DETROIT MI
48201-2153
US

IV. Provider business mailing address

42301 CHERRY HILL RD
CANTON MI
48188-9801
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4622
  • Fax:
Mailing address:
  • Phone: 734-981-4040
  • Fax: 734-981-2683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901017941
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: