Provider Demographics
NPI:1598007692
Name:EXECUTIVE DENTISTRY DDS PC
Entity Type:Organization
Organization Name:EXECUTIVE DENTISTRY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FAGD, FKOL
Authorized Official - Phone:313-914-4440
Mailing Address - Street 1:23044 CHERRY HILL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1066
Mailing Address - Country:US
Mailing Address - Phone:313-914-4440
Mailing Address - Fax:
Practice Address - Street 1:23044 CHERRY HILL ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1066
Practice Address - Country:US
Practice Address - Phone:313-914-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty