Healthcare Provider Details

I. General information

NPI: 1326670886
Provider Name (Legal Business Name): PLYMOUTH ARDENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40400 ANN ARBOR RD E STE 103
PLYMOUTH MI
48170-4590
US

IV. Provider business mailing address

40400 ANN ARBOR RD E STE 103
PLYMOUTH MI
48170-4590
US

V. Phone/Fax

Practice location:
  • Phone: 734-459-7110
  • Fax: 734-459-0314
Mailing address:
  • Phone: 734-459-7110
  • Fax: 734-459-0314

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: LAURA BURKEEN
Title or Position: MANAGER
Credential:
Phone: 734-459-7110