Provider Demographics
NPI:1699724864
Name:MIDWESTERN DENTAL OF CANTON
Entity type:Organization
Organization Name:MIDWESTERN DENTAL OF CANTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-582-8150
Mailing Address - Street 1:5050 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3249
Mailing Address - Country:US
Mailing Address - Phone:313-582-8150
Mailing Address - Fax:313-582-6015
Practice Address - Street 1:45650 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5432
Practice Address - Country:US
Practice Address - Phone:734-207-3740
Practice Address - Fax:734-207-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty