Provider Demographics
NPI:1346632122
Name:MODERN DENTAL CENTER
Entity Type:Organization
Organization Name:MODERN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZETOUNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-644-7815
Mailing Address - Street 1:50810 ROMEO PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1123
Mailing Address - Country:US
Mailing Address - Phone:734-644-7815
Mailing Address - Fax:
Practice Address - Street 1:50810 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1123
Practice Address - Country:US
Practice Address - Phone:734-644-7815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16908261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental