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General NPI Number Information
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NPI Number | 1720127384
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Entity Type | Individual
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Provider Name | JOHN P. ILITCH D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 15311 W MCNICHOLS RD
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City | DETROIT
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State | MI
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Zip | 48235-3723
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Country | US
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Telephone | 313-838-0490
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Fax | 248-539-3347
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Provider Business Mailing Address
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Address Line | 17770 STONEBROOK DR
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City | NORTHVILLE
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State | MI
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Zip | 48168-4329
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Country | US
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Telephone | 313-838-0490
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Fax | 248-539-3347
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 14256
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License Number State | MI
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