=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437671799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D2 DENTAL OF MICHIGAN, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2017
-----------------------------------------------------
Last Update Date | 07/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14736 MACK AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48215-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-412-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 N OAK PARK AVE STE 310
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENT
-----------------------------------------------------
Name | MR. BORIS LABINOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-613-4542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------