Healthcare Provider Details

I. General information

NPI: 1619355070
Provider Name (Legal Business Name): MACOMB CHILDREN'S DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51299 ROMEO PLANK RD
MACOMB MI
48042-4114
US

IV. Provider business mailing address

51299 ROMEO PLANK RD
MACOMB MI
48042-4114
US

V. Phone/Fax

Practice location:
  • Phone: 586-697-5272
  • Fax:
Mailing address:
  • Phone: 586-697-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901018743
License Number StateMI

VIII. Authorized Official

Name: AMIT BATRA
Title or Position: DDS/OWNER
Credential: DDS
Phone: 586-697-5272