MEDICARE: MACOMB-SHELBY DENTAL

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

General Provider Information

NPI Number	:	1093158669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACOMB-SHELBY DENTAL

Provider Business Mailing Address
First Line	:	51210 ROMEO PLANK RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	51210 ROMEO PLANK RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4129
Country	:	US
Telephone Number	:	586-677-7944
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. NANCY YEZAK
Credential	:
Telephone Number	:	586-677-7944

Provider Enumeration Date	:	04/12/2013
Last Update Date	:	04/12/2013

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Directions to “MACOMB-SHELBY DENTAL ” Practice Location

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