MEDICARE: FAMILY DENTAL CENTER PC

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	122300000X	Dentist	018718	MI
2	1223G0001X	General Practice Dentistry	016079	MI
3	1223G0001X	General Practice Dentistry	107660	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4731390	OTHER	MI	DR GREWAL
3	4970960	OTHER	MI	DR JELSCH

General Provider Information

NPI Number	:	1063690683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTAL CENTER PC

Provider Business Mailing Address
First Line	:	3912 18 MILE ROAD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314
Country	:	US
Telephone Number	:	586-264-3200
Fax Number	:	586-264-3241

Provider Business Practice Location Address
First Line	:	3912 18 MILE ROAD
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314
Country	:	US
Telephone Number	:	586-264-3200
Fax Number	:	586-264-3241

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDUARDO G REGALADO JR.
Credential	:	DDS
Telephone Number	:	586-264-3200

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	02/06/2008

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