Healthcare Provider Details

I. General information

NPI: 1356732309
Provider Name (Legal Business Name): FIFTH STREET DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8048 5TH ST
DEXTER MI
48130-1033
US

IV. Provider business mailing address

8048 5TH ST
DEXTER MI
48130-1033
US

V. Phone/Fax

Practice location:
  • Phone: 734-426-2220
  • Fax: 734-426-4480
Mailing address:
  • Phone: 734-426-2220
  • Fax: 734-426-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2901017984
License Number StateMI

VIII. Authorized Official

Name: DR. DONI R MALLIA
Title or Position: DENTIST
Credential: D.D.S.
Phone: 734-426-2220