Healthcare Provider Details

I. General information

NPI: 1063615300
Provider Name (Legal Business Name): THE TRAVELING TOOTH STATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30704 HUNTSMAN DR E
FARMINGTON HILLS MI
48331-1378
US

IV. Provider business mailing address

30704 HUNTSMAN DR E
FARMINGTON HILLS MI
48331-1378
US

V. Phone/Fax

Practice location:
  • Phone: 313-244-3498
  • Fax:
Mailing address:
  • Phone: 248-788-3845
  • Fax: 248-788-3073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELANIE D COLBERT
Title or Position: OWNER
Credential: R.D.H. BS
Phone: 313-244-3498