Healthcare Provider Details

I. General information

NPI: 1922086370
Provider Name (Legal Business Name): SEVEN LAKES PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 TORREY RD SUITE 500
FENTON MI
48430-3327
US

IV. Provider business mailing address

1100 TORREY RD SUITE 500
FENTON MI
48430-3327
US

V. Phone/Fax

Practice location:
  • Phone: 810-750-3400
  • Fax:
Mailing address:
  • Phone: 810-750-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number18270
License Number StateMI

VIII. Authorized Official

Name: DIEGO VELASQUEZ-PLATA
Title or Position: PRESIDENT
Credential: DDS, MSD
Phone: 810-750-3400