=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467684399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONNE FAMILY DENTAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 11/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 KINGSWAY CT
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48183-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-671-8414
-----------------------------------------------------
Fax | 734-671-8234
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1550 KINGSWAY CT
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48183-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-671-8414
-----------------------------------------------------
Fax | 734-671-8234
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS ASST.
-----------------------------------------------------
Name | MS. KELLY M PUSKARICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-671-8414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901017885
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901019162
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901010486
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------