=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013216639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTHETIC AND IMPLANTS DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2011
-----------------------------------------------------
Last Update Date | 03/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 S WASHINGTON AVE
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48067-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-399-8600
-----------------------------------------------------
Fax | 248-399-8613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1206 S WASHINGTON AVE
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48067-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-399-8600
-----------------------------------------------------
Fax | 248-399-8613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. KATHRYN SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-399-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 2901019637
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------