Healthcare Provider Details

I. General information

NPI: 1245753342
Provider Name (Legal Business Name): RIVERCREST ORTHODONTICS DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 W AVON RD STE 16
ROCHESTER HILLS MI
48307-2759
US

IV. Provider business mailing address

930 W AVON RD STE 16
ROCHESTER HILLS MI
48307-2759
US

V. Phone/Fax

Practice location:
  • Phone: 248-652-1244
  • Fax:
Mailing address:
  • Phone: 248-652-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901021680
License Number StateMI

VIII. Authorized Official

Name: DR. HADI DAIA
Title or Position: PRESIDENT
Credential: DDS, MS, FRCD(C)
Phone: 248-652-1244