Provider Demographics
NPI:1427568237
Name:AMAZING DENTAL PORT HURON PLLC
Entity Type:Organization
Organization Name:AMAZING DENTAL PORT HURON PLLC
Other - Org Name:AMAZING DENTAL PORT HURON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAMS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-910-4819
Mailing Address - Street 1:4035 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4035 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3801
Practice Address - Country:US
Practice Address - Phone:810-385-9766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental