Healthcare Provider Details

I. General information

NPI: 1770164980
Provider Name (Legal Business Name): TRU DENTAL MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 ROWE AVE
PORTLAND MI
48875-1645
US

IV. Provider business mailing address

155 ROWE AVE
PORTLAND MI
48875-1645
US

V. Phone/Fax

Practice location:
  • Phone: 517-647-6205
  • Fax: 517-647-6205
Mailing address:
  • Phone: 517-647-6205
  • Fax: 517-647-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100