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General NPI Number Information
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NPI Number | 1205030277
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Entity Type | Organization
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Legal Business Name | RENAISSANCE DENTAL PC
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Dates
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Enumeration Date | 06/13/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7330 W WARREN AVE
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City | DETROIT
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State | MI
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Zip | 48210-1041
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Country | US
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Telephone | 313-340-9293
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Fax | 313-340-9293
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Provider Business Mailing Address
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Address Line | 7330 W WARREN AVE
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City | DETROIT
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State | MI
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Zip | 48210-1041
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Country | US
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Telephone | 313-340-9293
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Fax | 313-340-9293
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Authorized Official
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Title or Position | DENTIST
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Name | DR. WALLACE L WALKER JR.
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Credential | DDS
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Telephone | 313-340-9293
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12881
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License Number State | MI
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