Provider Demographics
NPI:1306135413
Name:VISITING DENTAL ASSOCIATES P.C.
Entity type:Organization
Organization Name:VISITING DENTAL ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-535-7770
Mailing Address - Street 1:20770 KELLY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3114
Mailing Address - Country:US
Mailing Address - Phone:586-779-3333
Mailing Address - Fax:
Practice Address - Street 1:20770 KELLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3114
Practice Address - Country:US
Practice Address - Phone:586-779-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI17336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty