Provider Demographics
NPI:1932567906
Name:CLINTON TOWNSHIP DENTAL GROUP
Entity type:Organization
Organization Name:CLINTON TOWNSHIP DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ROCCO
Authorized Official - Last Name:BIELKIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-412-7100
Mailing Address - Street 1:43230 GARFIELD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1162
Mailing Address - Country:US
Mailing Address - Phone:586-412-7100
Mailing Address - Fax:586-412-7105
Practice Address - Street 1:43230 GARFIELD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-412-7100
Practice Address - Fax:586-712-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015810261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental