MEDICARE: SHORES DENTAL CENTER, P.C.

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	2901015365	MI
2	122300000X	Dentist	2901011906	MI

General Provider Information

NPI Number	:	1952357204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHORES DENTAL CENTER, P.C.

Provider Business Mailing Address
First Line	:	31549 HARPER AVE
Second Line	:
City	:	ST CLAIR SHORES
State	:	MI
Zip	:	48082-2455
Country	:	US
Telephone Number	:	586-293-1530
Fax Number	:	586-293-1537

Provider Business Practice Location Address
First Line	:	31549 HARPER AVE
Second Line	:
City	:	ST CLAIR SHORES
State	:	MI
Zip	:	48082-2455
Country	:	US
Telephone Number	:	586-293-1530
Fax Number	:	586-293-1537

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. PAMELA LYNN KALICH
Credential	:
Telephone Number	:	586-293-1530

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/22/2020

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