Healthcare Provider Details

I. General information

NPI: 1932541455
Provider Name (Legal Business Name): PERIODONTAL SPECIALISTS OF FLINT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4252 S LINDEN RD
FLINT MI
48507-2953
US

IV. Provider business mailing address

8185 HOLLY RD SUITE 19
GRAND BLANC MI
48439-2444
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-1890
  • Fax: 810-733-3619
Mailing address:
  • Phone: 810-695-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: SUHEIL M BOUTROS
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 810-695-6444