Healthcare Provider Details

I. General information

NPI: 1699015339
Provider Name (Legal Business Name): PROFESSIONAL PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2013
Last Update Date: 02/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30101 HOOVER RD STE A
WARREN MI
48093-6572
US

IV. Provider business mailing address

30101 HOOVER RD STE A
WARREN MI
48093-6572
US

V. Phone/Fax

Practice location:
  • Phone: 586-751-0070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2901017594
License Number StateMI

VIII. Authorized Official

Name: DR. STEPHEN MERAW
Title or Position: PRESIDENT
Credential: DDS
Phone: 586-751-0070