Healthcare Provider Details

I. General information

NPI: 1245234707
Provider Name (Legal Business Name): SUE ELLEN CICHOWSKI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 W WEBSTER RD
ROYAL OAK MI
48073-3700
US

IV. Provider business mailing address

2711 W WEBSTER RD
ROYAL OAK MI
48073-3700
US

V. Phone/Fax

Practice location:
  • Phone: 248-399-8100
  • Fax: 248-399-8286
Mailing address:
  • Phone: 248-399-8100
  • Fax: 248-399-8286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13595
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: