Provider Demographics
NPI:1548447576
Name:PERIODONTAL SPECIALISTS OF CLARKSTON
Entity type:Organization
Organization Name:PERIODONTAL SPECIALISTS OF CLARKSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUHEIL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BOUTROS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:810-695-6444
Mailing Address - Street 1:6803 DIXIE HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5101
Mailing Address - Country:US
Mailing Address - Phone:248-625-1721
Mailing Address - Fax:248-625-5475
Practice Address - Street 1:6803 DIXIE HWY STE 1
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5101
Practice Address - Country:US
Practice Address - Phone:248-625-1721
Practice Address - Fax:248-625-5475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI169091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty