Healthcare Provider Details

I. General information

NPI: 1366954836
Provider Name (Legal Business Name): DENTAL SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3526 W SAGINAW ST
LANSING MI
48917
US

IV. Provider business mailing address

350 PINE RIDGE DR
BLOOMFIELD HILLS MI
48304-2139
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-2539
  • Fax:
Mailing address:
  • Phone: 248-931-1151
  • Fax: 248-594-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RANDALL SHAW
Title or Position: MANAGER
Credential:
Phone: 248-931-1151