MEDICARE: GENTLE DENTAL JEFFERSON 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	122300000X	Dentist

General Provider Information

NPI Number	:	1831336502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENTLE DENTAL JEFFERSON PLLC

Provider Business Mailing Address
First Line	:	529 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-4324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	529 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-4324
Country	:	US
Telephone Number	:	313-963-3336
Fax Number	:	313-963-6464

Authorized Official
Title or Position	:	INSURANCE DIRECTOR
Name	:	MICHAEL COLE
Credential	:
Telephone Number	:	727-726-1611

Provider Enumeration Date	:	01/16/2009
Last Update Date	:	01/16/2009

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