Provider Demographics
NPI:1194084780
Name:DETALMAX PC
Entity type:Organization
Organization Name:DETALMAX PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOUGHTELING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-784-8950
Mailing Address - Street 1:6655 ALPINE AVE NW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8000
Mailing Address - Country:US
Mailing Address - Phone:616-784-8950
Mailing Address - Fax:616-784-9553
Practice Address - Street 1:6655 ALPINE AVE NW
Practice Address - Street 2:SUITE 1
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8000
Practice Address - Country:US
Practice Address - Phone:616-784-8950
Practice Address - Fax:616-784-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010118201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI82071DMMedicare PIN