MEDICARE: LINCOLN PARK FAMILY DENTISTRY DDS PC

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	122300000X	Dentist	12551	MI
2	122300000X	Dentist	12122	MI
3	122300000X	Dentist	12305	MI

General Provider Information

NPI Number	:	1649371121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN PARK FAMILY DENTISTRY DDS PC

Provider Business Mailing Address
First Line	:	3326 FORT STREET
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146
Country	:	US
Telephone Number	:	313-381-0343
Fax Number	:	313-386-0331

Provider Business Practice Location Address
First Line	:	3326 FORT ST
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146
Country	:	US
Telephone Number	:	313-381-0343
Fax Number	:	313-386-0331

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEWART S MARKOFSKY
Credential	:	DDS
Telephone Number	:	313-381-0343

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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