MEDICARE: DR. SUE ELLEN CICHOWSKI D.D.S.

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	13595	MI

General Provider Information

NPI Number	:	1245234707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUE ELLEN CICHOWSKI D.D.S.

Provider Business Mailing Address
First Line	:	2711 W WEBSTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-3700
Country	:	US
Telephone Number	:	248-399-8100
Fax Number	:	248-399-8286

Provider Business Practice Location Address
First Line	:	2711 W WEBSTER RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-3700
Country	:	US
Telephone Number	:	248-399-8100
Fax Number	:	248-399-8286

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2005
Last Update Date	:	07/08/2007

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