Provider Demographics
NPI:1639738743
Name:ORTHODONTICS CENTER OF NOVI, PC
Entity Type:Organization
Organization Name:ORTHODONTICS CENTER OF NOVI, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMNOON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-0880
Mailing Address - Street 1:2211 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3007
Mailing Address - Country:US
Mailing Address - Phone:313-565-0880
Mailing Address - Fax:313-565-2305
Practice Address - Street 1:27250 WIXOM RD STE B
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1116
Practice Address - Country:US
Practice Address - Phone:313-565-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336225713Medicaid