Healthcare Provider Details

I. General information

NPI: 1932800802
Provider Name (Legal Business Name): BOW TIE ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 ELIZABETH LAKE RD STE 203
WATERFORD MI
48328-3290
US

IV. Provider business mailing address

2677 ELIZABETH LAKE RD STE 203
WATERFORD MI
48328-3290
US

V. Phone/Fax

Practice location:
  • Phone: 248-682-8811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES WILLIAMS
Title or Position: OWNER
Credential:
Phone: 313-530-7096