Provider Demographics
NPI:1497180798
Name:ODICARE PC
Entity type:Organization
Organization Name:ODICARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESPONSIBLE PARTY
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREL
Authorized Official - Middle Name:N
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-341-3684
Mailing Address - Street 1:27201 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5127
Mailing Address - Country:US
Mailing Address - Phone:586-558-8004
Mailing Address - Fax:
Practice Address - Street 1:15510 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1343
Practice Address - Country:US
Practice Address - Phone:313-863-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4718431Medicaid