Organization
PRO DENTAL MI 1 PC
Active
Other names
Destiny Dental of Grand River
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SIMONE WILSON-ADELEKE MPA-PPA (DIRECTOR OF CREDENTIALING)
(732) 914-3991
Entity
Organization
Contact information
Practice address
21427 GRAND RIVER AVE STE 100, DETROIT, MI 48219-3897
(313) 412-2100
(313) 766-7734
Mailing address
10 WOODBRIDGE CENTER DR STE 520, WOODBRIDGE, NJ 07095-1152
(732) 914-1422
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
1223G0001X
General Practice Dentistry
—
—
Other
Enumeration date
09/18/2024
Last updated
09/18/2024
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