Healthcare Provider Details

I. General information

NPI: 1285172213
Provider Name (Legal Business Name): MATT DEMERLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29425 RYAN RD
WARREN MI
48092-2203
US

IV. Provider business mailing address

29425 RYAN RD
WARREN MI
48092-2203
US

V. Phone/Fax

Practice location:
  • Phone: 586-755-9340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901600835
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: