MEDICARE: WATERFORD KIDS DENTAL CLUB, 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
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1689224818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERFORD KIDS DENTAL CLUB, PLLC

Provider Business Mailing Address
First Line	:	4220 SURREY CROSS
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-1669
Country	:	US
Telephone Number	:	248-909-2132
Fax Number	:

Provider Business Practice Location Address
First Line	:	3801 ELIZABETH LAKE RD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-3017
Country	:	US
Telephone Number	:	248-909-2132
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. REBECA URQUIOLA
Credential	:	DDS
Telephone Number	:	248-909-2132

Provider Enumeration Date	:	09/19/2019
Last Update Date	:	09/19/2019

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