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General NPI Number Information
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NPI Number | 1265682900
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Entity Type | Organization
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Legal Business Name | OLDE ORCHARD PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 09/30/2008
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Last Update Date | 09/30/2008
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Provider Practice Location Address
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Address Line | 40105 GRAND RIVER AVE STE 2
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City | NOVI
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State | MI
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Zip | 48375-2170
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Country | US
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Telephone | 248-478-3232
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Fax |
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Provider Business Mailing Address
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Address Line | 40105 GRAND RIVER AVE STE 2
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City | NOVI
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State | MI
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Zip | 48375-2170
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Country | US
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Telephone | 248-478-3232
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Fax |
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Authorized Official
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Title or Position | ASSISTANT OFFICE MANAGER
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Name | DAPHNE WEST
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Credential |
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Telephone | 248-478-3232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901011539
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License Number State | MI
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