Skip Navigation

Provider Information for 1558527812

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1558527812

Calendar   Last Updated:  2010-01-07
  Certification Date: 


Name Value
NPI 1558527812
Enumeration Date 2008-08-05
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 3243 CAMDEN DR
TROY, MI 48084-7028
United States

Phone: 248-649-2228 | Fax:
View Map External Link
Primary Practice Address 4780 ROCHESTER RD
TROY, MI 48085-4929
United States

Phone: 248-689-9012 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice MI 2901017525