Provider Demographics
NPI:1689193278
Name:BEDAIR, ENNIS MALIK (BDS)
Entity Type:Individual
Prefix:
First Name:ENNIS
Middle Name:MALIK
Last Name:BEDAIR
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:ANAS
Other - Middle Name:MALIK
Other - Last Name:MOHAMMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 E. MEDICAL CENTER DR., TOWSLEY CENTER G1218
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 E. MEDICAL CENTER DR., MED INN C213A
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-936-5950
Practice Address - Fax:734-232-5015
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2952000370122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist