Healthcare Provider Details

I. General information

NPI: 1124162185
Provider Name (Legal Business Name): WILLIAM ALLAN PATCHAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W WASHINGTON AVE SUITE 105
JACKSON MI
49201-2169
US

IV. Provider business mailing address

2317 SMALLEY ST
JACKSON MI
49203-3727
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-8340
  • Fax:
Mailing address:
  • Phone: 517-784-5012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901011397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: