Basic Information
Provider Information
NPI: 1033557863
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VODOPYANOV
FirstName: DMITRY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1500 E. MEDICAL CENTER DRIVE
Address2: B1 208 TAUBMAN CENTER
City: ANN ARBOR
State: MI
PostalCode: 481085018
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1500 E. MEDICAL CENTER DRIVE
Address2: B1 208 TAUBMAN CENTER
City: ANN ARBOR
State: MI
PostalCode: 481085018
CountryCode: US
TelephoneNumber: 7342326048
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/14/2013
LastUpdateDate: 06/14/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X2901021004MIY Dental ProvidersDentist 

No ID Information.


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