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General NPI Number Information
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NPI Number | 1225779325
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Entity Type | Organization
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Legal Business Name | SOUTHGATE ARDENT PLLC
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 04/05/2022
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Provider Practice Location Address
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Address Line | 13703 NORTHLINE RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-1866
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Country | US
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Telephone | 734-284-8088
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Fax | 734-284-0522
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Provider Business Mailing Address
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Address Line | 13703 NORTHLINE RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-1866
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Country | US
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Telephone | 734-284-8088
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Fax | 734-284-0522
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Authorized Official
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Title or Position | MANAGER
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Name | MS. LAURA BURKEEN
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Credential |
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Telephone | 734-284-8088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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