Healthcare Provider Details

I. General information

NPI: 1861781643
Provider Name (Legal Business Name): EDGARDO ZUNIGA DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 01/31/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E LAKE ST
SOUTH LYON MI
48178
US

IV. Provider business mailing address

112 E LAKE ST
SOUTH LYON MI
48178
US

V. Phone/Fax

Practice location:
  • Phone: 248-617-3747
  • Fax: 248-617-3748
Mailing address:
  • Phone: 248-617-3747
  • Fax: 248-617-3748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901600663
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: