MEDICARE: DR. HOWARD PAUL POTOCSKY 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	1223G0001X	General Practice Dentistry	18547	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J172880	OTHER	MI	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295731420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOWARD PAUL POTOCSKY D.D.S

Provider Business Mailing Address
First Line	:	17128 FORT ST
Second Line	:
City	:	RIVERVIEW
State	:	MI
Zip	:	48192-6619
Country	:	US
Telephone Number	:	734-281-3200
Fax Number	:	734-281-3890

Provider Business Practice Location Address
First Line	:	17128 FORT ST
Second Line	:
City	:	RIVERVIEW
State	:	MI
Zip	:	48192-6619
Country	:	US
Telephone Number	:	734-281-3200
Fax Number	:	734-281-3890

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	09/10/2007

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