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General NPI Number Information
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NPI Number | 1700207669
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Entity Type | Organization
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Legal Business Name | DENTAL CHOICE MOBILE DENTISTRY, PLLC
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Dates
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Enumeration Date | 12/19/2013
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Last Update Date | 12/19/2013
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Provider Practice Location Address
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Address Line | 634 PRINCESS DR
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City | CANTON
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State | MI
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Zip | 48188-1144
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Country | US
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Telephone | 734-788-8061
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 37047
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City | OAK PARK
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State | MI
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Zip | 48237-0047
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | GLORIA JOHNSON
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Credential |
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Telephone | 313-790-0094
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901011776
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License Number State | MI
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