Provider Demographics
NPI:1144863283
Name:FAIRCOURT DENTAL PC
Entity type:Organization
Organization Name:FAIRCOURT DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VITALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-882-2000
Mailing Address - Street 1:20040 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2360
Mailing Address - Country:US
Mailing Address - Phone:313-882-2000
Mailing Address - Fax:313-882-2515
Practice Address - Street 1:20040 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2360
Practice Address - Country:US
Practice Address - Phone:313-882-2000
Practice Address - Fax:313-882-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty