Provider Demographics
NPI:1548444102
Name:GOLNICK PEDIATRIC DENTAL ASSOCIATES
Entity type:Organization
Organization Name:GOLNICK PEDIATRIC DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:313-292-7777
Mailing Address - Street 1:21213 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1834
Mailing Address - Country:US
Mailing Address - Phone:313-292-7777
Mailing Address - Fax:313-292-7515
Practice Address - Street 1:21213 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1834
Practice Address - Country:US
Practice Address - Phone:313-292-7777
Practice Address - Fax:313-292-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016484261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental