NPIMap

Organization Active NPI

Pro Dental Mi 1 PC

Doing business as Destiny Dental of Dearborn

  • Dentist
  • Dearborn, MI
National Provider Identifier
1669209938
Registry record updated Sep 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
Legal business name
PRO DENTAL MI 1 PC
Doing business as
Destiny Dental of Dearborn
Practice address
16201 Ford Rd Ste 115
Dearborn, MI 48126-2876
Phone
(313) 451-8304
Fax
(313) 789-7993
NPI assigned
Sep 19, 2024
Last updated
Sep 19, 2024By the provider in NPPES
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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X NU Primary
General Practice Dentistry 1223G0001X NU

Addresses

Primary practice location

16201 Ford Rd Ste 115
Dearborn, MI 48126-2876

Mailing address

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

Other names 1

  • Destiny Dental of Dearborn 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

16201 Ford Rd
Ste 115
Dearborn, MI 48126
Phone (313) 451-8304

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": "1669209938",
    "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": "16201 FORD RD STE 115",
            "city": "DEARBORN",
            "state": "MI",
            "postal_code": "481262876",
            "telephone_number": "313-451-8304",
            "fax_number": "313-789-7993"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRO DENTAL MI 1 PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-09-19",
        "last_updated": "2024-09-19",
        "certification_date": "2024-09-18",
        "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": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Destiny Dental of Dearborn",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Dearborn, 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.