Healthcare Provider Details

I. General information

NPI: 1295902302
Provider Name (Legal Business Name): DISTINCTIVE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58047 VAN DYKE RD SUITE #101
WASHINGTON TWP MI
48094-4000
US

IV. Provider business mailing address

58047 VAN DYKE RD SUITE #101
WASHINGTON TWP MI
48094-4000
US

V. Phone/Fax

Practice location:
  • Phone: 586-207-6013
  • Fax: 586-207-6300
Mailing address:
  • Phone: 586-207-6013
  • Fax: 586-207-6300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS MICHAEL DAVIDSON
Title or Position: DENTIST
Credential: DDS
Phone: 586-207-6013