Healthcare Provider Details

I. General information

NPI: 1922818749
Provider Name (Legal Business Name): TROY JOHN R DENTAL PRACTICE ENTITY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 JOHN R RD STE 100
TROY MI
48085-3647
US

IV. Provider business mailing address

4101 JOHN R RD STE 100
TROY MI
48085-3647
US

V. Phone/Fax

Practice location:
  • Phone: 248-680-0775
  • Fax:
Mailing address:
  • Phone: 248-680-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: RITA DELLY
Title or Position: CEO
Credential:
Phone: 248-697-6870