Provider Demographics
NPI:1972794352
Name:PROSTHODONTIC & IMPLANT CONSULTANTS PC
Entity type:Organization
Organization Name:PROSTHODONTIC & IMPLANT CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:248-855-6655
Mailing Address - Street 1:6177 ORCHARD LAKE ROAD
Mailing Address - Street 2:SUITE #120
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-855-6655
Mailing Address - Fax:248-855-0803
Practice Address - Street 1:6177 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE #120
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-855-6655
Practice Address - Fax:248-855-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
MI2901010565204E00000X
MI2901010587204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2758821Medicaid
MI3239144Medicaid
MI5636930Medicare PIN
MI2758821Medicaid