Provider Demographics
NPI:1033808787
Name:LEILA, ALI (DMD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:LEILA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22211 GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:DEABORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-437-0051
Mailing Address - Fax:
Practice Address - Street 1:22211 GREGORY ST
Practice Address - Street 2:
Practice Address - City:DEABORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-437-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901601752122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program