Provider Demographics
NPI:1285880872
Name:EASTLAND FAMILY DENTISTRY
Entity type:Organization
Organization Name:EASTLAND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:G
Authorized Official - Last Name:KEYORKGY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:313-372-8580
Mailing Address - Street 1:16068 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1416
Mailing Address - Country:US
Mailing Address - Phone:313-372-8580
Mailing Address - Fax:313-372-7739
Practice Address - Street 1:16068 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1416
Practice Address - Country:US
Practice Address - Phone:313-372-8580
Practice Address - Fax:313-372-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI165981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3369505Medicaid