NPIMap

Organization Active NPI

Supreme Dental of Plymouth Road PC

  • Dentist
  • Detroit, MI
National Provider Identifier
1649693102
Registry record updated Feb 3, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
SUPREME DENTAL OF PLYMOUTH ROAD PC
Practice address
20720 Plymouth Rd
Detroit, MI 48228-1275
Phone
(313) 342-1997
NPI assigned
Feb 3, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2014

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

Authorized official

Name
Michele Bloxson
Title
President
Phone
(313) 416-6806

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X Primary

Addresses

Primary practice location

20720 Plymouth Rd
Detroit, MI 48228-1275

Mailing address

27201 Ryan Rd
Warren, MI 48092-5127

Other identifiers 1

IdentifierTypeStateIssuer
1003804303MedicaidMI

National Provider Directory

National Provider Directory

NPI Registry JSON

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

{
    "created_epoch": "1391385600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1391385600000",
    "number": "1649693102",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "27201 RYAN RD",
            "city": "WARREN",
            "state": "MI",
            "postal_code": "480925127"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20720 PLYMOUTH RD",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482281275",
            "telephone_number": "313-342-1997"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUPREME DENTAL OF PLYMOUTH ROAD PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-03",
        "last_updated": "2014-02-03",
        "status": "A",
        "authorized_official_last_name": "BLOXSON",
        "authorized_official_first_name": "MICHELE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "313-416-6806"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1003804303",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2014; 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.