Healthcare Provider Details

I. General information

NPI: 1053365536
Provider Name (Legal Business Name): DEXTER FAMILY EYE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 BAKER RD
DEXTER MI
48130-1126
US

IV. Provider business mailing address

3045 BAKER RD
DEXTER MI
48130-1126
US

V. Phone/Fax

Practice location:
  • Phone: 734-424-0097
  • Fax: 734-424-0097
Mailing address:
  • Phone: 734-424-0097
  • Fax: 734-424-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003917
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003966
License Number StateMI

VIII. Authorized Official

Name: MRS. KELLY DAVINA CARRIER
Title or Position: DOCTOR
Credential: OD
Phone: 734-424-0097