Healthcare Provider Details

I. General information

NPI: 1417917584
Provider Name (Legal Business Name): KEITH DAVID NOWICKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32545 GARFIELD RD
FRASER MI
48026-3843
US

IV. Provider business mailing address

32545 GARFIELD RD
FRASER MI
48026-3843
US

V. Phone/Fax

Practice location:
  • Phone: 586-293-3633
  • Fax: 586-293-5683
Mailing address:
  • Phone: 586-293-3633
  • Fax: 586-293-5683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17331
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: