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General NPI Number Information
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NPI Number | 1578889515
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Entity Type | Organization
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Legal Business Name | COMMERCE PERIODONTOLOGY, PLLC
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Dates
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Enumeration Date | 04/15/2010
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Last Update Date | 04/15/2010
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Provider Practice Location Address
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Address Line | 2600 UNION LAKE RD SUITE 130
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City | COMMERCE TOWNSHIP
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State | MI
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Zip | 48382-3588
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Country | US
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Telephone | 248-242-6277
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Fax |
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Provider Business Mailing Address
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Address Line | 2600 UNION LAKE RD SUITE 130
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City | COMMERCE TOWNSHIP
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State | MI
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Zip | 48382-3588
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Country | US
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Telephone | 248-242-6277
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JASON SOUYIAS
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Credential | DDS
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Telephone | 248-242-6277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 2901019200
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License Number State | MI
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