Provider Demographics
NPI:1689798530
Name:COMMUNITY DENTISTRY PLUS,P,C
Entity Type:Organization
Organization Name:COMMUNITY DENTISTRY PLUS,P,C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KHAYRI
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-790-3738
Mailing Address - Street 1:30480 SHOREHAM ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5368
Mailing Address - Country:US
Mailing Address - Phone:248-790-3738
Mailing Address - Fax:
Practice Address - Street 1:18161 W 12 MILE RD
Practice Address - Street 2:SUIT 2
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2662
Practice Address - Country:US
Practice Address - Phone:248-790-3738
Practice Address - Fax:248-552-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI290101092201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty