=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447640040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROSSE POINTE FAMILY DENTISTRY MACOMB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46401 ROMEO PLANK RD SUITE 2
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-286-7337
-----------------------------------------------------
Fax | 586-286-9974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46401 ROMEO PLANK RD SUITE 2
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-286-7337
-----------------------------------------------------
Fax | 586-286-9974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENT AGENT
-----------------------------------------------------
Name | DR. CHRIS C PANAGOS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 586-286-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13571
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------