Basic Information
| Provider Information | |||||||||
| NPI: | 1366576118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANJIRATH | ||||||||
| FirstName: | PREETHA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | BDS MDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347641543 | ||||||||
| FaxNumber: | 7347642469 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347641543 | ||||||||
| FaxNumber: | 7347642469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901017325 | MI | Y | Dental Providers | Dentist | 1223G0001X | 2901017325 | MI | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1958111510 | 01 | MI | BCBS OF MI MED SURGICAL | OTHER | D173250 | 01 | MI | BCBS OF MI DENTAL | OTHER |