Healthcare Provider Details

I. General information

NPI: 1063740108
Provider Name (Legal Business Name): EDWARD R. ESSAYAN DDS, PC (PROFESSIONAL CORPORATION)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 ORCHARD LAKE RD SUITE 200
WEST BLOOMFIELD MI
48322-2384
US

IV. Provider business mailing address

6161 ORCHARD LAKE RD SUITE 200
WEST BLOOMFIELD MI
48322-2384
US

V. Phone/Fax

Practice location:
  • Phone: 248-851-3767
  • Fax: 248-865-9455
Mailing address:
  • Phone: 248-851-3767
  • Fax: 248-865-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901009679
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901009679
License Number StateMI

VIII. Authorized Official

Name: DR. EDWARD R. ESSAYAN
Title or Position: DDS - ORTHODONTIST - PRESIDENT
Credential: DDS - ORTHODONTIST
Phone: 248-851-3767