=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508974387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMTRAMCK DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9541 JOS CAMPALL HAMTRAMCK DENTAL CENTER
-----------------------------------------------------
City | HAMTRACK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-972-4700
-----------------------------------------------------
Fax | 313-972-1105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9541 JOS CAMPALL
-----------------------------------------------------
City | HAMTRACK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-972-4700
-----------------------------------------------------
Fax | 313-972-1105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | WILBERT PURIFOY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 313-972-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10915
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13106
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 17875
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 17410
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------