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General NPI Number Information
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NPI Number | 1053254193
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Entity Type | Organization
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Legal Business Name | DETROIT DENTAL RX PLLC
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Dates
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Enumeration Date | 04/13/2026
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Last Update Date | 04/13/2026
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Provider Practice Location Address
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Address Line | 15510 LIVERNOIS AVE
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City | DETROIT
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State | MI
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Zip | 48238-1343
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Country | US
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Telephone | 313-217-0014
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Fax | 313-246-1886
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Provider Business Mailing Address
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Address Line | 27201 RYAN RD
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City | WARREN
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State | MI
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Zip | 48092-5127
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | ALEX WOLICKI
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Credential |
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Telephone | 586-558-8004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State |
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