# SUPREME DENTAL OF PLYMOUTH ROAD PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1649693102
- **Authorized official:** MICHELE BLOXSON (PRESIDENT)
- **Authorized official phone:** (313) 416-6806

## Contact information

- **Practice address:** 20720 PLYMOUTH RD, DETROIT, MI 48228-1275
- **Practice address phone:** (313) 342-1997
- **Mailing address:** 27201 RYAN RD, WARREN, MI 48092-5127

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | NULL | Yes |
| 122300000X | Dentist | — | — | Yes |

## Other

- **Enumeration date:** 02/03/2014
- **Last updated:** 02/03/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1003804303 | — | MI |