Provider Demographics
NPI:1902810237
Name:DECAROLIS DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:DECAROLIS DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-645-3700
Mailing Address - Street 1:24255 W 13 MILE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4320
Mailing Address - Country:US
Mailing Address - Phone:248-645-3700
Mailing Address - Fax:248-647-0600
Practice Address - Street 1:24255 W 13 MILE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4320
Practice Address - Country:US
Practice Address - Phone:248-645-3700
Practice Address - Fax:248-647-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010114311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty