Healthcare Provider Details

I. General information

NPI: 1881005957
Provider Name (Legal Business Name): DENTAL DREAMS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6109 S CEDAR ST
LANSING MI
48911-5714
US

IV. Provider business mailing address

350 N CLARK ST STE 600 C/O KOS SERVICES
CHICAGO IL
60654-4782
US

V. Phone/Fax

Practice location:
  • Phone: 810-789-5880
  • Fax:
Mailing address:
  • Phone: 312-274-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH LEE
Title or Position: ENROLLMENT COORDINATOR
Credential:
Phone: 312-274-4526