MEDICARE: A DENTAL CENTER-DOWNRIVER

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	305S00000X	Point of Service	17288	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D172880	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1528064771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A DENTAL CENTER-DOWNRIVER

Provider Business Mailing Address
First Line	:	17128 FORT ST
Second Line	:
City	:	RIVERVIEW
State	:	MI
Zip	:	48193-6619
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	:	48193-6619
Country	:	US
Telephone Number	:	734-281-3200
Fax Number	:	734-281-3890

Authorized Official
Title or Position	:	BILLING
Name	:	DR. HOWARD POTOCSKY
Credential	:	D.D.S
Telephone Number	:	734-281-3200

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	09/05/2007

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17128 FORT ST
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Directions to “A DENTAL CENTER-DOWNRIVER ” Practice Location

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