=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013123488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL DAVID BORTOLOTTI D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51863 SCHOENHERR RD. SUITE 104
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-5867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-731-6300
-----------------------------------------------------
Fax | 586-731-6011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51863 SCHOENHERR RD SUITE 104
-----------------------------------------------------
City | SHELBY TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-731-6300
-----------------------------------------------------
Fax | 586-731-6011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 015401
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------