MEDICARE: LINCOLN PARK DENTAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	11350	MI

General Provider Information

NPI Number	:	1033383716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN PARK DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	3577 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-4114
Country	:	US
Telephone Number	:	313-388-0103
Fax Number	:	313-388-3219

Provider Business Practice Location Address
First Line	:	3577 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-4114
Country	:	US
Telephone Number	:	313-388-0103
Fax Number	:	313-388-3219

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTHONY WAYNE STINES
Credential	:	D.D.S.
Telephone Number	:	313-388-0103

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	04/15/2008

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1740462423 — KEITH SMITH CHIROPRACTIC PROFESSIONAL CORPORATION
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