Basic Information
| Provider Information | |||||||||
| NPI: | 1316509326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SABLE | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | SOLOMON | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6498 LAKESHORE ST | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483231428 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2215 FULLER RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481052303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2019 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901600200 | MI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | S140603772356 | 01 | MI | STATE DRIVER LICENSE | OTHER | 2901600200 | 01 | MI | STATE DENTAL LICENSE | OTHER |