Provider Demographics
NPI:1194127258
Name:DAVID R BACKUS DDS
Entity type:Organization
Organization Name:DAVID R BACKUS DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-683-8188
Mailing Address - Street 1:4633 DOW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48324-2326
Mailing Address - Country:US
Mailing Address - Phone:248-683-8188
Mailing Address - Fax:
Practice Address - Street 1:4633 DOW RIDGE RD
Practice Address - Street 2:
Practice Address - City:ORCHARD LAKE
Practice Address - State:MI
Practice Address - Zip Code:48324-2326
Practice Address - Country:US
Practice Address - Phone:248-683-8188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-20
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901012277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty