Provider Demographics
NPI:1790274686
Name:BAIN, DINA FAKHOURI (DO)
Entity Type:Individual
Prefix:DR
First Name:DINA
Middle Name:FAKHOURI
Last Name:BAIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 370
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5403
Mailing Address - Country:US
Mailing Address - Phone:248-625-4055
Mailing Address - Fax:
Practice Address - Street 1:12000 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3570
Practice Address - Country:US
Practice Address - Phone:586-570-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151013348207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology