Healthcare Provider Details

I. General information

NPI: 1790695765
Provider Name (Legal Business Name): MY WARREN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3456 E 12 MILE RD STE 2
WARREN MI
48092-2511
US

IV. Provider business mailing address

3456 E 12 MILE RD STE 2
WARREN MI
48092-2511
US

V. Phone/Fax

Practice location:
  • Phone: 586-486-4600
  • Fax: 586-486-4624
Mailing address:
  • Phone: 586-486-4600
  • Fax: 586-486-4624

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: JOSEPH THAYIL
Title or Position: PRESIDENT
Credential: DDS
Phone: 586-486-4600