=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467049684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELUXE DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2020
-----------------------------------------------------
Last Update Date | 01/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3307 ROCHESTER RD
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-820-7766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3760 S DORT HWY
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48507-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-820-7766
-----------------------------------------------------
Fax | 810-243-0454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMBER KIZY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-820-7766
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------