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General NPI Number Information
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NPI Number | 1194962753
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Entity Type | Organization
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Legal Business Name | MICHIGAN IMPLANTS & PERIODONTICS INSTITUTE, P.L.C.
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Dates
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Enumeration Date | 01/19/2009
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Last Update Date | 01/19/2009
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Provider Practice Location Address
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Address Line | 2755 CARPENTER RD SUITE 2NE
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City | ANN ARBOR
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State | MI
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Zip | 48108-1186
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Country | US
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Telephone | 734-975-1743
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Fax |
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Provider Business Mailing Address
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Address Line | 2755 CARPENTER RD SUITE 2NE
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City | ANN ARBOR
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State | MI
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Zip | 48108-1186
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Country | US
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Telephone | 734-975-1743
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. KELLY MISCH
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Credential | D.D.S., M.S.
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Telephone | 734-975-1743
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2901018946
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2901019093
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License Number State | MI
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