Provider Demographics
NPI:1497946636
Name:CLARKSTON FAMILY DENTAL
Entity type:Organization
Organization Name:CLARKSTON FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-625-2424
Mailing Address - Street 1:6778 BLUEGRASS DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6778 BLUEGRASS DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-1400
Practice Address - Country:US
Practice Address - Phone:248-625-2424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty