Healthcare Provider Details

I. General information

NPI: 1215297676
Provider Name (Legal Business Name): NEW YOU WONDERLAND MANAGEMENT- LIVONIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2012
Last Update Date: 05/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29475 PLYMOUTH RD
LIVONIA MI
48150-2112
US

IV. Provider business mailing address

23225 NORTHWESTERN HWY
SOUTHFIELD MI
48075-7707
US

V. Phone/Fax

Practice location:
  • Phone: 734-237-5755
  • Fax: 734-237-5756
Mailing address:
  • Phone: 248-595-0161
  • Fax: 248-799-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JANE PAISOPOULOS
Title or Position: PRESIDENT
Credential:
Phone: 248-595-0161