=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366904708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TMJ & SLEEP THERAPY CENTRE OF MACOMB COUNTY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2019
-----------------------------------------------------
Last Update Date | 04/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50475 GRATIOT SUITE 4
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50475 GRATIOT SUITE 4
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
Fax | 586-949-5366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROMAN SADIKOFF
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 586-949-5363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------