Provider Demographics
NPI:1063615300
Name:THE TRAVELING TOOTH STATION
Entity type:Organization
Organization Name:THE TRAVELING TOOTH STATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:RDH BS
Authorized Official - Phone:313-244-3498
Mailing Address - Street 1:30704 HUNTSMAN DR E
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1378
Mailing Address - Country:US
Mailing Address - Phone:248-788-3845
Mailing Address - Fax:248-788-3073
Practice Address - Street 1:30704 HUNTSMAN DR E
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-1378
Practice Address - Country:US
Practice Address - Phone:313-244-3498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063615300Medicaid