Provider Demographics
NPI:1073790838
Name:FORT DENTAL CENTER
Entity Type:Organization
Organization Name:FORT DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:313-386-9404
Mailing Address - Street 1:3515 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4101
Mailing Address - Country:US
Mailing Address - Phone:313-386-9404
Mailing Address - Fax:313-386-9405
Practice Address - Street 1:3515 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-4101
Practice Address - Country:US
Practice Address - Phone:313-386-9404
Practice Address - Fax:313-386-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty