=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780143982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDRENS DENTAL SPECIALISTS OF HAZEL PARK PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2019
-----------------------------------------------------
Last Update Date | 08/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22241 JOHN R RD
-----------------------------------------------------
City | HAZEL PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48030-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-336-0356
-----------------------------------------------------
Fax | 248-336-0357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22241 JOHN R RD
-----------------------------------------------------
City | HAZEL PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48030-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-336-0356
-----------------------------------------------------
Fax | 248-336-0357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IFECHIDE NWABUEZE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-336-0356
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------