MEDICARE: OAKLAND FAMILY DENTAL CARE, PLC

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	261QD0000X	Dental Clinic/Center	2901013245	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	264873	OTHER		UNITED CONCORDIA INS
2	D132450	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801919287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKLAND FAMILY DENTAL CARE, PLC

Provider Business Mailing Address
First Line	:	7184 MEADOWBROOK DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-3552
Country	:	US
Telephone Number	:	734-844-8438
Fax Number	:

Provider Business Practice Location Address
First Line	:	7184 MEADOWBROOK DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-3552
Country	:	US
Telephone Number	:	734-844-8438
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. JANE E BANCUK
Credential	:	DDS
Telephone Number	:	734-844-8438

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	02/09/2015

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