Healthcare Provider Details

I. General information

NPI: 1144401811
Provider Name (Legal Business Name): IVAN DENNIS POTOCSKY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 OAKWOOD
MELVINDALE MI
48122-1211
US

IV. Provider business mailing address

3113 OAKWOOD
MELVINDALE MI
48122-1211
US

V. Phone/Fax

Practice location:
  • Phone: 313-381-3850
  • Fax: 313-389-0046
Mailing address:
  • Phone: 313-381-3850
  • Fax: 313-389-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number09561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: