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NPI Code Detail

MEDICARE: OFFICE 4 PLLC

MEDICARE: OFFICE 4 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
1261QD0000XDental Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11770597890OTHERMIDENTAL
21316232655OTHERMIDENTIST

General Provider Information

NPI Number : 1578045548
Entity Type Code : Organization
Provider Name (Legal Business Name) : OFFICE 4 PLLC
Provider Business Mailing Address
First Line : 350 PINE RIDGE DR
Second Line :
City : BLOOMFIELD HILLS
State : MI
Zip : 48304-2139
Country : US
Telephone Number : 248-931-1151
Fax Number : 248-594-2221
Provider Business Practice Location Address
First Line : 2555 SPRING ARBOR RD
Second Line :
City : JACKSON
State : MI
Zip : 49203-3601
Country : US
Telephone Number : 517-787-8321
Fax Number :
Authorized Official
Title or Position : OWNER
Name : DR. RANDALL LOREN SHAW
Credential : DDS, MS.
Telephone Number : 248-931-1151
Provider Enumeration Date : 09/05/2018
Last Update Date : 11/24/2020

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