Healthcare Provider Details

I. General information

NPI: 1407450877
Provider Name (Legal Business Name): OFFICE 5 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S LAFAYETTE ST
SOUTH LYON MI
48178-1405
US

IV. Provider business mailing address

350 PINE RIDGE DR
BLOOMFIELD HILLS MI
48304-2139
US

V. Phone/Fax

Practice location:
  • Phone: 248-437-4119
  • Fax:
Mailing address:
  • Phone: 248-931-1151
  • Fax: 248-594-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL LOREN SHAW
Title or Position: OWNER
Credential: DDS, MS
Phone: 248-931-1151