MEDICARE: TIA VANSUILICHEM DDS

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	2901602179	MI

General Provider Information

NPI Number	:	1871340521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIA VANSUILICHEM DDS

Provider Business Mailing Address
First Line	:	2915 JOHN R ST APT 307
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2912
Country	:	US
Telephone Number	:	616-272-8599
Fax Number	:

Provider Business Practice Location Address
First Line	:	22341 WEST RD
Second Line	:
City	:	WOODHAVEN
State	:	MI
Zip	:	48183-3157
Country	:	US
Telephone Number	:	734-671-1620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2024
Last Update Date	:	08/08/2024

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