Healthcare Provider Details

I. General information

NPI: 1801848734
Provider Name (Legal Business Name): DOUGLAS EADES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W 11 MILE RD
ROYAL OAK MI
48067-2447
US

IV. Provider business mailing address

809 W 11 MILE RD
ROYAL OAK MI
48067-2447
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-8730
  • Fax: 248-547-8767
Mailing address:
  • Phone: 248-547-8730
  • Fax: 248-547-8767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016976
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: