Healthcare Provider Details

I. General information

NPI: 1790461630
Provider Name (Legal Business Name): BUBBLE GUM KIDS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 DIX TOLEDO RD
SOUTHGATE MI
48195
US

IV. Provider business mailing address

15401 DIX TOLEDO RD
SOUTHGATE MI
48195
US

V. Phone/Fax

Practice location:
  • Phone: 734-999-9292
  • Fax: 734-999-9393
Mailing address:
  • Phone: 734-999-9292
  • Fax: 734-999-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMY PAUNDLAY
Title or Position: SR. VICE PRESIDENT OF OPERATOPMS
Credential:
Phone: 203-400-9999