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General NPI Number Information
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NPI Number | 1093264731
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Entity Type | Organization
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Legal Business Name | SOUTHFIELD KIDS DENTIST PLC
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Dates
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Enumeration Date | 09/22/2016
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Last Update Date | 01/20/2022
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Provider Practice Location Address
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Address Line | 18900 W 10 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2669
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Country | US
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Telephone | 248-565-3332
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Fax |
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Provider Business Mailing Address
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Address Line | 18900 W 10 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2669
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Country | US
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Telephone | 248-565-3332
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | IFECHIDE NWABUEZE
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Credential | DMD
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Telephone | 248-217-7997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901020260
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License Number State | MI
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