Provider Demographics
NPI:1679289664
Name:KHREIZAT, MAYA (DMD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:KHREIZAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6464 REUTER ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2221
Mailing Address - Country:US
Mailing Address - Phone:313-289-3102
Mailing Address - Fax:
Practice Address - Street 1:25147 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2198
Practice Address - Country:US
Practice Address - Phone:313-277-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist