Healthcare Provider Details

I. General information

NPI: 1356455893
Provider Name (Legal Business Name): NICHOLAS THOMAS RAFAILL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49050 SCHOENHERR RD SUITE 400
SHELBY TOWNSHIP MI
48315-3856
US

IV. Provider business mailing address

24 SUNNINGDALE DR
GROSSE POINTE SHORES MI
48236-1662
US

V. Phone/Fax

Practice location:
  • Phone: 586-247-5544
  • Fax:
Mailing address:
  • Phone: 313-640-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number16261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: