Healthcare Provider Details

I. General information

NPI: 1760165518
Provider Name (Legal Business Name): DENNIS FERNANDO MATIAS CALERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

772 GREEN RD APT 305
YPSILANTI MI
48198-3467
US

V. Phone/Fax

Practice location:
  • Phone: 734-575-0467
  • Fax:
Mailing address:
  • Phone: 787-457-2864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451023815
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: