=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093185910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROMAN SADIKOFF PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 10/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50475 GRATIOT AVE STE 4
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48051-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
Fax | 586-343-5366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50475 GRATIOT AVE SUITE 4
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48051-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
Fax | 586-343-5366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROMAN SADIKOFF
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 17371
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------