Provider Demographics
NPI:1164258752
Name:ROSS FAMILY DENTISTRY
Entity type:Organization
Organization Name:ROSS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-395-2733
Mailing Address - Street 1:170 WAMPLERS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9585
Mailing Address - Country:US
Mailing Address - Phone:517-592-3003
Mailing Address - Fax:517-592-5785
Practice Address - Street 1:170 WAMPLERS LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9585
Practice Address - Country:US
Practice Address - Phone:517-592-3003
Practice Address - Fax:517-592-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801389499Medicaid