Basic Information
| Provider Information | |||||||||
| NPI: | 1932279882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENTS OF THE UNIVERSITY OF MICHIGAN DENTAL FACULTY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347649185 | ||||||||
| FaxNumber: | 7346478090 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347643155 | ||||||||
| FaxNumber: | 7346154784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | POLVERINI | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DEAN, UNIV OF MI SCHOOL OF DENTISTR | ||||||||
| AuthorizedOfficialTelephone: | 7347649185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0106X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Pathology | 1223P0221X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0700X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 1223S0112X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223X0008X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Radiology | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | 2901016040 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 970H110770 | 01 | MI | BCBS OF MI ORALSURGERY | OTHER | XX19411 | 01 | MI | HEALTH PLUS OF MI | OTHER | 1006664 | 01 | MI | MCLAREN ADVANTAGE | OTHER | 2667609 | 05 | OH | MEDICAID | 43-20001 | 01 | MI | PHP OF MI | OTHER | 43-28004 | 01 | MI | PHP OF MI | OTHER | 4504346 | 05 | MI | MEDICAID | 190H110980 | 01 | MI | BCBS OF MI MEDSURG # | OTHER | 025748 | 01 | MI | MIDWEST HEALTH | OTHER | 1476671 | 01 | MI | UNITED CONCORDIA | OTHER | 4504373 | 05 | MI | MEDICAID | 88054 | 01 | MI | DELTA DENTAL OF MI - GENL | OTHER | D800363 | 01 | MI | BCBS OF MI GENLDENTIST | OTHER | QMXPR0014549 | 01 | MI | MOLINA HEALTHCARE | OTHER |