Healthcare Provider Details

I. General information

NPI: 1629371182
Provider Name (Legal Business Name): WEST BLOMMFIELD DENTAL AND ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ORCHARD LAKE RD 211
WEST BLOOMFIELD MI
48322-3405
US

IV. Provider business mailing address

6900 ORCHARD LAKE RD 211
WEST BLOOMFIELD MI
48322-3405
US

V. Phone/Fax

Practice location:
  • Phone: 248-851-5650
  • Fax: 248-851-5663
Mailing address:
  • Phone: 248-851-5650
  • Fax: 248-851-5663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number017174
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011884
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: GLEN BRIAN DAVIS
Title or Position: CEO
Credential:
Phone: 248-851-5650