Provider Demographics
NPI:1366155202
Name:DETROIT DENTAL SPA PLLC
Entity type:Organization
Organization Name:DETROIT DENTAL SPA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NACY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-419-7998
Mailing Address - Street 1:1117 GRISWOLD ST UNIT 1414
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1936
Mailing Address - Country:US
Mailing Address - Phone:832-419-7998
Mailing Address - Fax:
Practice Address - Street 1:2130 TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1344
Practice Address - Country:US
Practice Address - Phone:832-419-7998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental