Healthcare Provider Details

I. General information

NPI: 1992881635
Provider Name (Legal Business Name): I DENNIS POTOCSKY DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
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: DR. IVAN DENNIS POTOCSKY
Title or Position: OWNER
Credential: DDS
Phone: 313-381-3850