Basic Information
| Provider Information | |||||||||
| NPI: | 1083739262 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF MICHIGAN ORAL PATHOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4251 PLYMOUTH RD | ||||||||
| Address2: | BUILDING 3 SUITE 2400 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481092789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346478091 | ||||||||
| FaxNumber: | 7346478090 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347641543 | ||||||||
| FaxNumber: | 7347642469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | D'SILVA | ||||||||
| AuthorizedOfficialFirstName: | NISHA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7347641543 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS PHS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223P0106X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | 027740 | 01 | MI | MIDWEST HEALTH | OTHER | 190H110650 | 01 | MI | BCBS OF MI MED SURGICAL | OTHER | DD81014 | 01 | MI | M-CARE | OTHER | XX20091 | 01 | MI | HEALTH PLUS OF MI | OTHER | QMXPR0013422 | 01 | MI | MOLINA HEALTHCARE OF MI | OTHER |