Healthcare Provider Details

I. General information

NPI: 1013591908
Provider Name (Legal Business Name): IDEAL DENTISTRY OF NORTON SHORES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SEMINOLE RD STE 102
NORTON SHORES MI
49441-6561
US

IV. Provider business mailing address

755 SEMINOLE RD STE 102
NORTON SHORES MI
49441-6561
US

V. Phone/Fax

Practice location:
  • Phone: 231-780-1100
  • Fax:
Mailing address:
  • Phone: 231-780-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AMANDA ROBERTSON
Title or Position: DENTIST
Credential: DDS
Phone: 989-313-1843