Healthcare Provider Details

I. General information

NPI: 1235506908
Provider Name (Legal Business Name): DEXTER PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12632 DEXTER AVE
DETROIT MI
48238-3340
US

IV. Provider business mailing address

12632 DEXTER AVE
DETROIT MI
48238-3340
US

V. Phone/Fax

Practice location:
  • Phone: 586-776-4185
  • Fax:
Mailing address:
  • Phone: 586-776-4185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SATISH RAVILAL MEHTA
Title or Position: MEMBER
Credential: MD
Phone: 313-378-4620