Provider Demographics
NPI:1871340521
Name:VANSUILICHEM, TIA (DDS)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:VANSUILICHEM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 JOHN R ST APT 307
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2912
Mailing Address - Country:US
Mailing Address - Phone:616-272-8599
Mailing Address - Fax:
Practice Address - Street 1:22341 WEST RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-3157
Practice Address - Country:US
Practice Address - Phone:734-671-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist