Provider Demographics
NPI:1255583910
Name:SHELBY PINES COSMETIC AND FAMILY DENTISTRY
Entity type:Organization
Organization Name:SHELBY PINES COSMETIC AND FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GADIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-739-1717
Mailing Address - Street 1:52871 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3264
Mailing Address - Country:US
Mailing Address - Phone:586-739-1717
Mailing Address - Fax:586-739-3362
Practice Address - Street 1:52871 MOUND RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3264
Practice Address - Country:US
Practice Address - Phone:586-739-1717
Practice Address - Fax:586-739-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010167651223G0001X
MI29010179311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty