Healthcare Provider Details

I. General information

NPI: 1710149026
Provider Name (Legal Business Name): SERGIO CUADROS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16100 KING RD
RIVERVIEW MI
48193-7972
US

IV. Provider business mailing address

143E MAIN ST
BENTON HARBOR MI
49022-4409
US

V. Phone/Fax

Practice location:
  • Phone: 734-479-3330
  • Fax:
Mailing address:
  • Phone: 269-927-1313
  • Fax: 269-934-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: