Provider Demographics
NPI:1447263181
Name:VIVIAN, ANDREA SUSAN (DDS, RPH)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:SUSAN
Last Name:VIVIAN
Suffix:
Gender:F
Credentials:DDS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50475 FELLOWS HILL DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6351
Mailing Address - Country:US
Mailing Address - Phone:734-453-7948
Mailing Address - Fax:
Practice Address - Street 1:50475 FELLOWS HILL DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6351
Practice Address - Country:US
Practice Address - Phone:734-453-7948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022074183500000X
MI2901014159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No183500000XPharmacy Service ProvidersPharmacist