Provider Demographics
NPI:1396825915
Name:MISRA, PREM LATA (DMD)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:LATA
Last Name:MISRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2393 LEXINGTON CIR N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-5913
Mailing Address - Country:US
Mailing Address - Phone:313-580-8077
Mailing Address - Fax:
Practice Address - Street 1:28541 FORD RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2843
Practice Address - Country:US
Practice Address - Phone:734-945-0026
Practice Address - Fax:313-369-2774
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010180261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice