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General NPI Number Information
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NPI Number | 1104819721
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Entity Type | Individual
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Provider Name | STEPHEN M GHEZZI D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/30/2005
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Last Update Date | 10/02/2014
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Provider Practice Location Address
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Address Line | 26018 PONTIAC TRL
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City | SOUTH LYON
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State | MI
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Zip | 48178-8050
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Country | US
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Telephone | 248-486-4030
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Fax | 855-778-2780
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Provider Business Mailing Address
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Address Line | 26018 PONTIAC TRL
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City | SOUTH LYON
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State | MI
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Zip | 48178-8050
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Country | US
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Telephone | 248-486-4030
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Fax | 855-778-2780
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 2901017960
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License Number State | MI
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