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General NPI Number Information
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NPI Number | 1215297676
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Entity Type | Organization
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Legal Business Name | NEW YOU WONDERLAND MANAGEMENT- LIVONIA
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Dates
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Enumeration Date | 05/20/2012
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Last Update Date | 05/20/2012
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Provider Practice Location Address
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Address Line | 29475 PLYMOUTH RD
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City | LIVONIA
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State | MI
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Zip | 48150-2112
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Country | US
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Telephone | 734-237-5755
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Fax | 734-237-5756
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Provider Business Mailing Address
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Address Line | 23225 NORTHWESTERN HWY
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City | SOUTHFIELD
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State | MI
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Zip | 48075-7707
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Country | US
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Telephone | 248-595-0161
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Fax | 248-799-7575
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Authorized Official
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Title or Position | PRESIDENT
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Name | JANE PAISOPOULOS
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Credential |
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Telephone | 248-595-0161
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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 |
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License Number State |
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