MEDICARE: J.A. PENZIEN, P.C.

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

General Provider Information

NPI Number	:	1578064481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J.A. PENZIEN, P.C.

Provider Business Mailing Address
First Line	:	55191 SHELBY RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	55191 SHELBY RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1150
Country	:	US
Telephone Number	:	248-650-5500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JONATHAN PENZIEN
Credential	:
Telephone Number	:	248-650-5500

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	02/26/2018

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