Healthcare Provider Details

I. General information

NPI: 1154619583
Provider Name (Legal Business Name): PERIODONTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40400 E. ANN ARBOR RD. SUITE 204A
PLYMOUTH MI
48170
US

IV. Provider business mailing address

22801 NEWMAN ST.
DEARBORN MI
48124-1740
US

V. Phone/Fax

Practice location:
  • Phone: 734-459-4077
  • Fax: 734-459-4084
Mailing address:
  • Phone: 313-274-8522
  • Fax: 313-274-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901015315
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID G DARANY
Title or Position: PRESIDENT
Credential: D.D.S., M.S.
Phone: 248-851-1034