Provider Demographics
NPI:1063690683
Name:FAMILY DENTAL CENTER PC
Entity type:Organization
Organization Name:FAMILY DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:G
Authorized Official - Last Name:REGALADO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-264-3200
Mailing Address - Street 1:3912 18 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314
Mailing Address - Country:US
Mailing Address - Phone:586-264-3200
Mailing Address - Fax:586-264-3241
Practice Address - Street 1:3912 18 MILE ROAD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:586-264-3200
Practice Address - Fax:586-264-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI018718122300000X
MI0160791223G0001X
MI1076601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1882470Medicaid
MI4731390OtherDR GREWAL
MI4970960OtherDR JELSCH