Healthcare Provider Details

I. General information

NPI: 1861606212
Provider Name (Legal Business Name): MICHIGAN ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1982 HOLLAND AVE
PORT HURON MI
48060
US

IV. Provider business mailing address

11300 E 13 MILE RD
WARREN MI
48093
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-7300
  • Fax: 810-985-7803
Mailing address:
  • Phone: 586-573-6860
  • Fax: 586-573-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN E FEGAN
Title or Position: SECRETARY
Credential: DDS
Phone: 586-573-6860