| Southfield Dental Pllc | |
|
17600 W 12 Mile Rd Suite 3 Southfield MI 48076-1910 | |
| (248) 569-6722 | |
| (248) 569-7409 |
| Full Name | Southfield Dental Pllc |
|---|---|
| Speciality | Dentist |
| Location | 17600 W 12 Mile Rd, Southfield, Michigan |
| Authorized Official Name and Position | Raymond A Fortson (MEMBER) |
| Authorized Official Contact | 2485696722 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Southfield Dental Pllc 17600 W 12 Mile Rd Suite 3 Southfield MI 48076-1910 Ph: (248) 569-6722 | Southfield Dental Pllc 17600 W 12 Mile Rd Suite 3 Southfield MI 48076-1910 Ph: (248) 569-6722 |
| NPI Number | 1104067644 |
|---|---|
| Provider Enumeration Date | 03/12/2009 |
| Last Update Date | 03/12/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104067644 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 2901014077 (Michigan) | Primary |
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