Provider Demographics
NPI:1427598598
Name:MAHAJAN, AMRUTA
Entity Type:Individual
Prefix:DR
First Name:AMRUTA
Middle Name:
Last Name:MAHAJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3267
Mailing Address - Country:US
Mailing Address - Phone:615-957-7554
Mailing Address - Fax:
Practice Address - Street 1:2425 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5667
Practice Address - Country:US
Practice Address - Phone:586-573-7334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010221451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics