MEDICARE: DISTINCTIVE 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
2	122300000X	Dentist

General Provider Information

NPI Number	:	1295902302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISTINCTIVE DENTAL

Provider Business Mailing Address
First Line	:	58047 VAN DYKE RD
Second Line	:	SUITE #101
City	:	WASHINGTON TWP
State	:	MI
Zip	:	48094-4000
Country	:	US
Telephone Number	:	586-207-6013
Fax Number	:	586-207-6300

Provider Business Practice Location Address
First Line	:	58047 VAN DYKE RD
Second Line	:	SUITE #101
City	:	WASHINGTON TWP
State	:	MI
Zip	:	48094-4000
Country	:	US
Telephone Number	:	586-207-6013
Fax Number	:	586-207-6300

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. THOMAS MICHAEL DAVIDSON
Credential	:	DDS
Telephone Number	:	586-207-6013

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	04/07/2025

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1568553857 — DR. THOMAS MICHAEL DAVIDSON D.D.S.
Practice Location Address:

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Directions to “DISTINCTIVE DENTAL ” Practice Location

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