Healthcare Provider Details

I. General information

NPI: 1295805026
Provider Name (Legal Business Name): FDA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 N LEROY F
FENTON MI
48430
US

IV. Provider business mailing address

1535 N LEROY F
FENTON MI
48430
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-5454
  • Fax: 810-629-8932
Mailing address:
  • Phone: 810-629-5454
  • Fax: 810-629-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017712
License Number StateMI

VIII. Authorized Official

Name: DR. JULIE KATHLEEN LEZOTTE
Title or Position: OWNER
Credential:
Phone: 810-629-5454