=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871706663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERIC N. SMITH,D.D.S, M.S. & JOHN F. SIVERTSON, D.D.S, M.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31636 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-522-7313
-----------------------------------------------------
Fax | 734-522-3203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31636 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-522-7313
-----------------------------------------------------
Fax | 734-522-3203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN F. SIVERTSON
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 734-522-7313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2901010031
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------