# PRO DENTAL MI 1 PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Destiny Dental of Grand River
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457188955
- **Authorized official:** MRS. SIMONE WILSON-ADELEKE MPA-PPA (DIRECTOR OF CREDENTIALING)
- **Authorized official phone:** (732) 914-3991

## Contact information

- **Practice address:** 21427 GRAND RIVER AVE STE 100, DETROIT, MI 48219-3897
- **Practice address phone:** (313) 412-2100
- **Practice address fax:** (313) 766-7734
- **Mailing address:** 10 WOODBRIDGE CENTER DR STE 520, WOODBRIDGE, NJ 07095-1152
- **Mailing address phone:** (732) 914-1422

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | NULL | Yes |
| 122300000X | Dentist | — | — | Yes |
| 1223G0001X | General Practice Dentistry | — | NULL | — |
| 1223G0001X | General Practice Dentistry | — | — | — |

## Other

- **Enumeration date:** 09/18/2024
- **Last updated:** 09/18/2024