Provider Demographics
NPI:1790349058
Name:DEARBORN DENTAL GROUP WEST
Entity Type:Organization
Organization Name:DEARBORN DENTAL GROUP WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DALAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELACHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-584-3210
Mailing Address - Street 1:25245 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1050
Mailing Address - Country:US
Mailing Address - Phone:313-584-3210
Mailing Address - Fax:
Practice Address - Street 1:25245 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1050
Practice Address - Country:US
Practice Address - Phone:313-584-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1255577409OtherNPPES