Provider Demographics
NPI:1285688531
Name:AGYEKUM, PAUL A SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:AGYEKUM
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 RAMBLING WAY
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1049
Mailing Address - Country:US
Mailing Address - Phone:248-338-7120
Mailing Address - Fax:
Practice Address - Street 1:13800 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4510
Practice Address - Country:US
Practice Address - Phone:313-491-2200
Practice Address - Fax:313-491-2210
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI122921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3106916Medicaid
MI3130288Medicaid