=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629230859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARREN DENTAL REFLECTIONS, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 09/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11552 E 12 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-573-7500
-----------------------------------------------------
Fax | 586-573-7502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11552 E 12 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-2644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-573-7500
-----------------------------------------------------
Fax | 586-573-7502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. GUS KALOTI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-573-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901017451
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------