Healthcare Provider Details

I. General information

NPI: 1528567401
Provider Name (Legal Business Name): OFFICE 3 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31590 SCHOOLCRAFT RD
LIVONIA MI
48150
US

IV. Provider business mailing address

350 PINE RIDGE DR
BLOOMFIELD HILLS MI
48304-2139
US

V. Phone/Fax

Practice location:
  • Phone: 248-931-1151
  • Fax:
Mailing address:
  • Phone: 248-931-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901013819
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901010706
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

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