Healthcare Provider Details

I. General information

NPI: 1225714157
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

4600 E. 14MILE RD, SUITE 3/4
WARREN MI
48092
US

IV. Provider business mailing address

4600 E. 14MILE RD, SUITE 3/4
WARREN MI
48092
US

V. Phone/Fax

Practice location:
  • Phone: 586-999-9000
  • Fax: 586-999-8000
Mailing address:
  • Phone: 586-999-9000
  • Fax:

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 OPERATIONS
Credential:
Phone: 203-400-9999