Provider Demographics
NPI:1104871250
Name:MICHIGAN HEAD & NECK INSTITUTE PC
Entity type:Organization
Organization Name:MICHIGAN HEAD & NECK INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-573-0438
Mailing Address - Street 1:3665 E 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4300
Mailing Address - Country:US
Mailing Address - Phone:586-573-0438
Mailing Address - Fax:586-573-0186
Practice Address - Street 1:3665 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4300
Practice Address - Country:US
Practice Address - Phone:586-573-0438
Practice Address - Fax:586-573-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI009174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M10630Medicare PIN
MI6449450001Medicare NSC