=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366597148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN M SUSHKO DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 N OLD WOODWARD AVE SUITE 201
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-644-5735
-----------------------------------------------------
Fax | 248-644-6465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 N OLD WOODWARD AVE SUITE 201
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-1342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-644-5735
-----------------------------------------------------
Fax | 248-644-6465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. JOHN MICHAEL SUSHKO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-644-5735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 1810857
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------