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General NPI Number Information
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NPI Number | 1225774789
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Entity Type | Organization
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Legal Business Name | PERIODONTAL SPECIALISTS OF CLARKSTON PC
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Dates
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Enumeration Date | 05/09/2022
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Last Update Date | 05/09/2022
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Provider Practice Location Address
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Address Line | 6803 DIXIE HWY STE 1
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City | CLARKSTON
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State | MI
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Zip | 48346-5101
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Country | US
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Telephone | 248-625-1721
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Fax | 248-625-5475
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Provider Business Mailing Address
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Address Line | 6803 DIXIE HWY STE 1
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City | CLARKSTON
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State | MI
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Zip | 48346-5101
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Country | US
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Telephone | 248-625-1721
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Fax | 248-625-5475
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | PAM STRADER
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Credential |
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Telephone | 248-625-1721
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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 |
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License Number State |
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