Provider Demographics
NPI:1497928493
Name:FAMILY DENTISTRY
Entity Type:Organization
Organization Name:FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:W
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-581-0710
Mailing Address - Street 1:10326 W WARREN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1659
Mailing Address - Country:US
Mailing Address - Phone:313-581-0717
Mailing Address - Fax:313-581-3590
Practice Address - Street 1:10326 W WARREN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1659
Practice Address - Country:US
Practice Address - Phone:313-581-0717
Practice Address - Fax:313-581-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015608261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1649320722OtherNPI