Provider Demographics
NPI:1558434480
Name:BOUTROS, SUHEIL M (DDS MS)
Entity Type:Individual
Prefix:
First Name:SUHEIL
Middle Name:M
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 GEDDES RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-9556
Mailing Address - Country:US
Mailing Address - Phone:734-485-3994
Mailing Address - Fax:810-732-4704
Practice Address - Street 1:300 E LONG LAKE
Practice Address - Street 2:SUITE 290
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:248-647-0516
Practice Address - Fax:248-433-1664
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI169091223P0300X
MI29010169091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics