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General NPI Number Information
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NPI Number | 1104288059
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Entity Type | Organization
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Legal Business Name | COHEN MODERN DENTISTRY P.C.
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Dates
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Enumeration Date | 03/21/2016
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Last Update Date | 01/04/2017
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Provider Practice Location Address
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Address Line | 14420 EUREKA RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-2058
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Country | US
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Telephone | 734-283-1263
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Fax |
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Provider Business Mailing Address
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Address Line | 14420 EUREKA RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-2058
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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 | OWNER
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Name | JASON M COHEN
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Credential |
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Telephone | 734-283-1263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901017871
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License Number State | MI
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