NPIMap

Organization Active NPI

Pro Dental Mi 1 PC

  • General Practice Dentistry
  • Pontiac, MI
National Provider Identifier
1063249332
Registry record updated Sep 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
PRO DENTAL MI 1 PC
Practice address
1101 E Walton Blvd Ste 300
Pontiac, MI 48340-1590
Phone
(248) 499-9989
Fax
(248) 481-9896
NPI assigned
Sep 19, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Simone Wilson-Adeleke, MPA-PPA
Title
Director of Credentialing
Phone
(732) 731-8398

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193200000X MULTI-SPECIALTY GROUP 1223G0001X Primary

Addresses

Primary practice location

1101 E Walton Blvd Ste 300
Pontiac, MI 48340-1590

Mailing address

10 Woodbridge Center Dr Ste 520
Woodbridge, NJ 07095-1152
Phone (732) 731-8398

Other names 1

  • Destiny Dental of Pontiac Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Destiny Dental of Dearborn12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1101 E Walton Blvd
Ste 300
Pontiac, MI 48340
Phone (248) 499-9989

10 Woodbridge Center Dr
Ste 520
Woodbridge, NJ 07095

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1726704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1726704000000",
    "number": "1063249332",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10 WOODBRIDGE CENTER DR STE 520",
            "city": "WOODBRIDGE",
            "state": "NJ",
            "postal_code": "070951152",
            "telephone_number": "732-731-8398"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 E WALTON BLVD STE 300",
            "city": "PONTIAC",
            "state": "MI",
            "postal_code": "483401590",
            "telephone_number": "248-499-9989",
            "fax_number": "248-481-9896"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO DENTAL MI 1 PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-09-19",
        "last_updated": "2024-09-19",
        "certification_date": "2024-09-19",
        "status": "A",
        "authorized_official_last_name": "WILSON-ADELEKE",
        "authorized_official_first_name": "SIMONE",
        "authorized_official_title_or_position": "DIRECTOR OF CREDENTIALING",
        "authorized_official_telephone_number": "732-731-8398",
        "authorized_official_credential": "MPA-PPA"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Destiny Dental of Pontiac",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pontiac, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.