MEDICARE: CANTON PEDIATRIC DENTISTRY, PLLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1184076697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANTON PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	1657 N CANTON CENTER RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2948
Country	:	US
Telephone Number	:	734-335-7270
Fax Number	:	734-667-4648

Provider Business Practice Location Address
First Line	:	1657 N CANTON CENTER RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2948
Country	:	US
Telephone Number	:	734-335-7270
Fax Number	:	734-667-4648

Authorized Official
Title or Position	:	BUSINESS COORDINATOR
Name	:	NESA MALCHEFF
Credential	:
Telephone Number	:	734-335-7270

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	07/08/2016

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